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An investigation of the relationship between reasons for participation in continuing professional education… Cividin, Theresa Marie 1995

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A N INVESTIGATION O F T H E RELATIONSHIP B E T W E E N REASONS F O R PARTICIPATION IN CONTINUING PROFESSIONAL E D U C A T I O N AND SUBSEQUENT APPLICATION O F L E A R N I N G by THERESA MARIE CIVIDIN A THESIS SUBMITTED IN P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F ARTS in T H E F A C U L T Y O F G R A D U A T E STUDIES (Department of Educational Studies) We accept this thesis as confonning to the required standard T H E UNIVERSTIY O F BRITISH C O L U M B I A December 1995 © Theresa Marie Cividin, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it 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 or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of tdttCgjlOY)a\ S\{ACJ\t5 The University of British Columbia Vancouver, Canada Date Decern bir 19, IM5 DE-6 (2/88) Abstract Continuing professional education (CPE) is regarded by professionals, professional associations, and the public as a means of ensuring competent practitioners. It is of limited use to the professional and their practice if what is learned is not used in, or to improve practice. Thus a better understanding of whether professionals apply what they learn to practice, and why, is of interest to adult educators. This study explores the linkage between voluntary and non-voluntary reasons for participation in CPE and subsequent application of learning. This investigation involved analyses of data collected as part of a large-scale evalu-ation of the Centre for Substance Abuse Protection Training Systems (CTS). The evaluation focused upon application of learning as a consequence of participation in the CTS workshop. Questionnaires were used to collect data from CTS workshop participants on three separate occasions; before, immediately after and two to four months following completion of the workshop. The sample was comprised of 281 health care professionals (physicians, nurses, mental health counsellors and rehabilitation specialists). Chi-square tests for association revealed significant associations between three volun-tary reasons for participation (need to do your job or volunteer activities differently, confirm what you are already doing is O.K., and chance to network with others) and application of learning. Non-significant associations were found between application of learning and one voluntary (general interest) and one non-voluntary (required by organization to participate) reason for participation. The three voluntary reasons for participation associated with application of learning imply intrinsic motivation as a linking factor in the association. Further analyses demonstrated that the data from the nursing sub-group influenced the data from the combined sample of health care professionals. Additional exploration of the ii nursing sample revealed that situational factors also contribute to application of learning. Greater application of learning was noted for participants who had previous training in substance abuse prevention, found the workshop useful and relevant, and had sufficient resources available at their workplace. It was concluded that in addition to intrinsic motiv-ation, situational factors also influence application of learning. iii Table of Contents Page Abstract ii Table of Contents iv List of Tables vii Acknowledgement xi CHAPTER ONE: INTRODUCTION 1 Introduction and Problem Statement 1 Purpose 2 Research Questions 3 Definition of Terms 3 Significance of this Investigation 4 CHAPTER TWO: LITERATURE REVIEW 7 Participation in Adult Education 8 Motivational Orientations/Reasons for Participation 9 Limitations of Reasons for Participation Research 11 Deterrents to Participation 12 Participation in Continuing Professional Education 12 Reasons for Participation in CPE 14 Influences on Reasons for Participating in CPE 19 Limitations of Existing Research on Reasons for Participation in CPE . . . 23 Summary of Research on Reasons for Participation in CPE 24 Evaluation of CPE 25 An Evolution of Evaluation Research 27 Summary of Evaluation Research in CPE 30 Transfer of Learning 31 Literature Review - Summary 37 CHAPTER THREE: RESEARCH DESIGN 39 Subjects 40 Instrumentation 42 Independent Variable 42 Dependent Variable 44 Instrument Reliability and Validity 45 Data Collection Procedures 47 Instrument Adminstration 47 Coding Procedure for Individual Respondents 47 Anonymity and Confidentiality 48 Procedure for Dealing with Response Bias 48 Data Analysis 49 iv Comparison of the Matched Samples to the Unmatched Samples 52 Descriptive Statistics 53 Cross-Tabulations and Chi-Square Tests for Association 53 Rationale for the Chi-Square Tests 54 One-Way ANOVA Tests of Indicators of Application of Learning by Situational and Demographic Characteristics 55 Rationale for Using the One-Way ANOVA Tests 56 Limitations of the Design 56 CHAPTER FOUR: RESULTS 58 Characteristics of the Respondents 59 Response Bias and External Validity 60 Summary of Reasons for Participation 64 Summary of Indicators of Application of Learning 66 Cross Tabulations and Chi-Square Tests of Association 67 Voluntary Reasons for Participation 68 Non-Voluntary Reasons for Participation 74 Cross Tabulations and Chi-Square Tests of Association for the Sample of Nurses 78 Voluntary Reasons for Participation 78 Non-Voluntary Reasons for Participation 84 Summary of Demographic Characteristics 86 Age of Respondents 87 Ethnicity 87 Level of Educational Attainment 88 Variables Influencing Application of Learning 91 CHAPTER FIVE: DISCUSSION AND LIMITATIONS 96 Response Bias and Representation of the Study Sample 96 Characteristics of the Respondents 97 Reasons for Participation 98 The Relationship Between Reasons for Participation and Application of Learning - Answering the Research Questions 100 Voluntary Reasons for Participation and Application of Learning 101 Non-Voluntary Reasons for Participation and Application of Learning . . 103 The Influence of Demographic and Situational Characteristics on Application of Learning 105 Limitations 108 CHAPTER SIX: SUMMARY, IMPLICATIONS AND FUTURE DIRECTIONS . . . . Ill Summary of Major Findings Ill Implications 112 Future Directions 116 References 118 v Table of Contents, Continued Page Appendix A - CSAP Data Log 124 Appendix B - Conceptual Framework 129 Appendix C - Data Collection Instruments 131 Appendix D - Frequency Distributions of Independent and Dependent Variables 140 vi List o f Tables Page Table 1. Summary of Reasons for Participation in CPE 15 Table 2. Summary of Response Rates for CTS Training Evaluations 41 Table 3. Results of One-Way ANOVA - Independent/Dependent Variables by Health Care Professional Group 51 Table 4. Respondents Classified by Health Care Professional Group 60 Table 5. Summary of Situational Characteristics of the Matched Sample and the Unmatched Sample 61 Table 6. Summary of 2-Tailed t-Tests of the Matched Sample and the Unmatched Sample 62 Table 7. Summary of Differences Between the Matched Sample and Unmatched Sample for the Combined Sample and Each Health Care Professional Sub-Group 63 Table 8. Summary of Reasons for Participation . . 66 Table 9. Summary of Indicators of Application of Learning 67 Table 10. 'Made changes in how you do your work or volunteer activities' by 'Need to do job or volunteer activities differently' 69 Table 11. 'Increased substance abuse prevention activities' by 'Need to do job or volunteer activities differently' 69 Table 12. 'Increased substance abuse prevention activities' by 'Confirm what you are already doing is O.K.' 70 Table 13. 'Made changes in how you do your work or volunteer activities' by 'Confirm what you are already doing is O.K.' 70 Table 14. 'Made changes in how you do your work or volunteer activities' by 'Chance to network with others' 71 Table 15. 'Increased substance abuse prevention activities' by 'Chance to network with others' 72 Table 16. 'Made changes in how you do your work or volunteer activities' by 'General interest' 72 Table 17. 'Increased substance abuse prevention activities' by 'General interest' . . . 73 Table 18. 'Made changes in how you do your work or volunteer activities' by 'Required by organization to participate' 74 Table 19. 'Increased substance abuse prevention activities' by 'Required by organization to participate' 75 Table 20. Summary of Associations Between the Reasons for Participation and 'Made changes in you do you work or volunteer activities' for the Combined Sample and Each Health Care Professional Sub-Group 76 Table 21. Summary of Associations Between the Reasons for Participation and 'Increased substance abuse prevention activities' for the Combined Sample and Each Health Care Professional Sub-Group 77 Table 22. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'Need to do job or volunteer activities differently' 79 vii List of Tables, Continued Page Table 23. Nurses Ratings of 'Made Changes in how you do your work or volunteer activities' by 'Need to do job or volunteer activities differently' 80 Table 24. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'Confirm what you are already doing is O.K.' 80 Table 25. Nurses' Rating of 'Made changes in how you do your work or volunteer activities' by 'Confirm what you are already doing is O.K.' . . . 81 Table 26. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'Chance to network with others' 82 Table 27. Nurses' Ratings of 'Made changes in how you do your work or volunteer activities' by 'Chance to network with others' 82 Table 28. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'General interest' 83 Table 29. Nurses' Ratings of 'Made changes in how you do your work or volunteer activities' by 'General interest' 84 Table 30. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'Required by organization to participate' 85 Table 31. Nurses Ratings of 'Made changes in how you your work or volunteer activities' by 'Required by organization to participate' 85 Table 32. Distribution of Respondents by Gender 86 Table 33. Distribution of Respondents by Age 87 Table 34. Distribution of Respondents by Ethnicity 88 Table 35. Distribution of Respondents by Level of Educational Attainment 89 Table 36. Distribution of Respondents by Organization of Employment 90 Table 37. Summary of One-Way ANOVAs for 'Made changes in how you do your work or volunteer activities' by Demographic and Situational Characteristics 94 Table 38. Summary of One-Way ANOVAs for 'Increased substance abuse prevention activities' by Demographic and Situational Characteristics . . . . 95 viii List of Figures Page Figure 1. Representation of the participation/learning process demonstrating the link between antecedents and outcomes 37 ix Acknowledgement Thanks go to my family and friends for putting up with me and providing support during the stressful times I encountered will working on this project. I am sure that they are happy I have finally completed this project and can return to the land of the living. Thanks also go my committee members, Dr. Judith Ottoson, Dr. Frank Echols, and Dr. Tom Sork for their valuable suggestions and advice. Dr. Judith Ottoson was always there for me with words of encouragement, guidance, and support. She contributed hours of work in helping with the completion of this project. Dr. Frank Echols was a godsend with his patience and guidance in helping me sift through, and make sense of the statistical analyses. This project, in its entirety, is a reflection of many hours of hard work that would not have been possible without the support of my family and friends and the contributions made by all committee members. x Chapter One Introduction Introduction and Problem Statement Motivational orientations which influence participation in adult education have been extensively investigated in the literature (Boshier, 1971, 1977; Boshier & Collins, 1985; Morstain & Smart, 1974). Through further research, the understanding of adults' reasons for participation in adult education has been extended to participants in continuing professional education (CPE) (Cervero, 1981; O'Connor, 1979; Scanlan & Darkenwald, 1985; Urbano, Jahns & Urbano, 1988). The advent of professionalism, rapidly changing technology, increasing public scrutiny, and a need for greater accountability has lead to CPE becoming an accepted responsibility of professionals (Houle, 1980). CPE is viewed as a means of improving competence, performance, and keeping knowledge and skills up-to-date. As a result, many professional associations require participation in CPE as a method of re-licensure, re-certification and maintenance of professional status. Most often the evidence used to determine continued competency, up-to-date practices, and current knowledge and skills is participation in CPE. What is learned or has changed in job performance is often not measured. Houle (1980) is in agreement with this analysis; he states "...the problem with measures of extent of participation is they carry no assurance that desired changes in competence or performance has occurred" (p.242). Literature supporting the evaluation of application of learning and performance changes is limited. The evaluation literature in the area of CPE focuses on four types of evaluations used to assess the effectiveness of CPE: participant satisfaction, knowledge or 2 skill changes, behaviour changes, and patient or client outcomes (Abrahamson, 1984; Bader, 1987; Bertram & Brooks-Bertram, 1977; Davis, et al., 1984; Dixon, 1978; Lloyd & Abrahamson, 1979; McLaughlin & Donaldson, 1991; Nona, Kenny & Johnson, 1988; Sork, 1984; Turnbull & Holt, 1993). Rarely do these types of evaluations link educational antecedents to educational outcomes. Although this link has not been addressed in the CPE literature, it has been addressed in the training literature. The existence of differences in learning and educational outcomes resulting from voluntary and non-voluntary participation in training programs has been noted by both Baldwin, Magjuka and Loher (1991) and Hicks and Klimoski (1987). Establishing such links with CPE may help explain why some CPE programs are effective and why some participants apply what is learned, while others do not. Linking the voluntary and non- voluntary reasons for participation in CPE to subsequent application of learning could provide a better understanding of the process of participation and application of learning. Purpose This study explores the linkage between antecedents to educational participation and subsequent educational outcomes. The relationship between participants' reasons for participation, the independent variable of this study, and subsequent application of learning, the dependent variable, is investigated. In particular, this study focuses on CPE workshops for health care professionals in the area of substance abuse prevention. The present study involves the use of an existing data base. The data was obtained as part of a large scale evaluation study of the Centre for Substance Abuse Protection (CSAP) Training Systems (CTS). A primary purpose of the CTS evaluation study is to investigate the application of learning from participation in the CTS training workshops. Data collection 3 began in 1993 and continued throughout 1995. This study uses data collected through questionnaires from the health care professionals attending CTS training workshops. Research Questions The primary question to be answered by this study is: 1. Do health care professionals' reasons for participation in CPE have an impact on their subsequent application of learning? A second general question is: 2. Do demographic and situational factors help explain the relationship between reasons for participation and application of learning? Definition of Terms The terms relevant to this study are defined below: Continuing Professional Education: Continuing professional education refers to formal learning experiences that enhance or update the knowledge, skills, or attitudes of the individual professional practitioner (AACP/APhA Task Force, 1975). More specifically it is defined as any planned, organized learning experience which builds upon basic knowledge obtained during pre-service education. Mandatory Continuing Professional Education: Continuing professional education programs and/or courses that are taken for credit as required by professional associations/organizations (usually at the provincial or state level) or the workplace in order to maintain professional licensure, certification or employment. The course content is usually specific to a profession. (Little, 1993). 4 Motivation: A process which leads an individual to attempt to satisfy a need (Lovell, 1980). Application of Learning: The extent to which knowledge, skills, and attitudes that are acquired from an educational program are subsequently used (Ford, 1994). More specifically defined as the degree to which an individual uses the knowledge and skills learned in the classroom, on the job in an effective and continuous manner (Georgensen, 1982). Voluntary Reasons for Participation: Reasons for participation which are related to needs and desires of the individual. Voluntary reasons for participation are an example of intrinsic motivation. Voluntary reasons include the following: professional advancement, need to do your job activities differently, confirm what you are already doing is O.K., general interest and chance to network with others. Non-Voluntary Reasons for Participation: Reasons for participation which are related to external influences or requirement mandated by others. These reasons for participation are not directly related to individual needs (professional or personal). Non-voluntary reasons for participation include the following: required to participate and mandatory continuing professional education requirements. Significance of this Investigation An awareness of the link between participants' reasons for participating in CPE and subsequent job performance is integral to program planning and evaluation. Thus, the findings of this study can inform program planning decisions, marketing, and evaluation processes and aid in revising mandatory CPE policies. 5 An understanding of the relationship between motivational orientations for participation and application of learning after completing the workshop will be helpful to adult educators. Establishing a link between the antecedents to participation in CPE and the outcomes provides for a more complete understanding of the participation-learning-application process. An understanding of why adults participate in CPE addresses half of the concept. By stopping here, we as adult educators, are neglecting the other half of the concept, that which occurs after participation. Participation in adult education is often presented as the endpoint. Hence, the goal is to increase participation in adult education without considering or assessing that to which participation leads. Participation in CPE is only a means to an end, not an end in itself. Participation is the means to learning, while application of learning should be considered the end point. What adults do with their learning after the program is important. An understanding of the link between motivational orientations and application of learning has implications for the program planning process. In particular, for planning the program content, delivery, and marketing. If reasons for participation are related to application of learning, participant motivation should be assessed prior to, or during, the program. Considering participant motivation and reasons for participating during planning stages (in particular during content planning, setting of program objectives, and delivery techniques) may help the adult educator encourage application of learning. Therefore, if motivation to learn and apply learning is lacking prior to participation, increasing participant motivation would be addressed as part of the content of the educational program. In addition, incorporating this concept into marketing strategies may help participants in deciding where to focus their educational efforts. 6 The concept of a linkage between reasons for educational participation and subsequent application also concerns the evaluation process. The effectiveness of a program cannot be determined entirely on the basis of outcomes or meeting of course objectives. The participants' reasons for participation should also be taken into account during the evaluation process. If participants are attending a program for reasons unrelated to application of learning can we say that the program is not effective if these participants do not apply what was learned? The proposed linkage between reasons for participation and application of learning provides more insight into the evaluative process. As a result, adult educators will have a better understanding of the results of program evaluation and what can be said about the effectiveness of programs. As such, this study is of significance. Adult educators, through a better understanding of the participation/application of learning link, will be better able to plan, implement, and evaluate continuing professional education programs that encourage and result in application of learning. 7 Chapter Two Literature Review This study investigates the relationship between participants' reasons for participation and subsequent application of learning. Although there is substantive literature about ante-cedents of educational participation and a growing body of literature on educational outcomes, there is little literature that links antecedents to outcomes. No linkage between the antecedents to participation in adult education programs and subsequent application of learning has been addressed in the adult education and evaluation literatures. These gaps in the literature are the link between the antecedents and the outcomes of C P E . Possible explanations for these gaps are the time needed to collect such data, the inherent cost of a lengthy study, and the difficulties entailed in measuring application of learning. Antecedents to participation include: reasons for participation, attitudes or intentions about participation, demographics, and the social situation. O f these antecedents, reasons for participation are of interest in this review. There is an abundance of adult education research based upon motivation theory. Researchers have investigated the reasons why adults participate in adult education programs and why professionals participate in C P E . Motivation theory and participation research help to inform the idea of antecedents to participation by providing information about why adults participate and what motivates participation. There is also a growing body of literature on the outcomes of participation in C P E . Some identified outcomes include degree of participant satisfaction, knowledge gain, attitude or behaviour change, application of learning, and change in client well-being. Application of learning is the outcome of interest in this study. 8 The linkage between the antecedents and outcomes is addressed by reviewing the transfer of learning literature. The training literature in business and industry attempts to demonstrate some linkages between antecedents to participation and subsequent outcomes, but is limited. In order to address the antecedents of interest, literature investigating reasons for participation in adult education and in CPE is reviewed. This will help determine if similar reasons motivate adults to participate in general adult education programs and CPE programs. The evaluation and transfer of training literature is then examined and the following concepts are introduced: outcomes of participation and the linkage between the outcomes and antecedents of participation. Participation in Adult Education The literature regarding participation in adult education is largely driven by the need to better understand why adults participate in adult education; who has access to adult educa-tion; who utilizes this access and why. Most participation research is situated in the discipline of psychology which provides a theoretical basis. Motivation theory helps explain why adults participate in adult education. Empirical studies based upon motivational orientations are used to supplement descriptive studies. Descriptive studies (i.e., Johnstone & Rivera, 1965) enable the researcher to describe the characteristics of adult learners and the various types of adult educational programs. Descriptive studies and sociological studies provide insight into the demographic and socio-economic factors of participation, while motivational orientations and reasons for participation explain the concept more fully. It is postulated that motivational orientations explain why some adults participate in adult education. 9 Participation research has occupied the adult education research community for decades. One of the first and most influential contributors is Houle (1961), who formulated a tripartite typology of adult learners. The learner types are based upon motivations for participation. The three types of adult learners identified by Houle are as follows: (a) goal-oriented adults who use education in order to accomplish specific objectives, (b) activity-oriented individuals who participate for reasons unrelated to the content but for the sake of the activity alone, and (c) learning-oriented adults who participate in education programs for the sake of knowledge alone. Identified limitations with Houle's research are the small sample size (22 subjects), possible selection effects (how the subjects were chosen) and lack of description of the interview schedule. Despite these limitations, Houle's research has made a significant contribution towards understanding why adults participate in adult education. Motivational Orientations/Reasons for Participation Boshier (1971) first tested the empirical findings of Houle's typology using factor analysis. This led to the development of the Education Participation Scale (EPS)(Boshier, 1982). Further explorations have established the validity and utility of the EPS (Boshier, 1977, 1976; Boshier & Collins, 1985; Morstain & Smart, 1974). The EPS is an instrument used to assess participant's reasons for participation. Forty-two reasons for participation are listed. Each reason is followed by four categories that reflect the extent to which the reason influenced the individual to enrol in the program. The four categories are no influence, little influence, moderate influence, and much influence. A description follows of how the technique of factor analysis is used to interpret the results of the EPS. 10 In Boshier's and Collins' (1985) large-scale empirical test of the Houle typology, participants were asked to rank the influence of each of the 42 reasons for participation listed on the EPS. Factor analysis was then used to achieve clustering of the 42 reasons. Factor analysis involves a series of related statistical techniques which helps the researcher group together conceptually related concepts. In this case, the motivational orientations are categories generated by the researcher from clustering of similar reasons for participation. From this procedure, six groupings of motivational orientations related to reasons for participation were identified. They are as follows: (a) professional advancement, (b) social stimulation, (c) external expectations, (d) social contact, (e) cognitive interest, (f) community service. Factor scoring, using regression analysis, is then done. Factor scoring helps demonstrate the extent to which participants were influenced by each of the motivational orientations. Using the EPS, Boshier and Collins (1985) concomitantly revealed that the goal and learning orientations were clearly described by Houle, but the activity orientations are more complex. The social and community aspects of the individuals, as well as individual expectations, play a role in what constitutes activity orientations as reasons for participation. This brief review samples the vast array of literature using motivational orientations to explain participation in adult education. Motivational orientations provide a basis upon which to explain why some adults are participating in adult education programs. Despite the 11 usefulness of this research in developing the basis of a theory towards participation, it does have its limitations. Limitations of Reasons for Participation Research The reasons for participation research is limited by survey methods which use self reported data from voluntary subjects. The specific limitations that were considered when interpreting the results will be discussed. First, responses given by the subjects may be influenced by what is perceived as socially desirable responses. As such, the subjects may be responding with what they feel the researcher wants to hear or with what they feel is a socially acceptable response. Second, the use of volunteers (those who choose to respond versus those who choose not to respond) as the subjects in an investigation limits the generalizability of the results. The results can only be compared to participants of adult education programs (i.e., not non-participants) who have characteristics similar to the volunteers; in most cases they are Caucasian, middle class, educated individuals. We can not be sure if those individuals who chose not to respond have significantly different characteristics resulting in markedly different responses. Consequently, the results may have been drastically altered if a sample population other than the volunteer sample was used. Last, the research done on motivational orientations is limited by what is defined as participation and adult education. Participation is generally defined as attending and actively learning. Adult education is generally defined as a planned educational program designed for adult learners. If these terms are operationalized and defined in different ways the results cannot be comparable. 12 Deterrents to Participation In addition to the reasons for participation literature, there is another prominent vein of participation research. This participation research is concerned with deterrents to partici-pation in adult education (Darkenwald & Valentine, 1985; Martindale & Drake, 1989; Scanlan & Darkenwald, 1984; Valentine & Darkenwald, 1990). As this type of participation research does not directly inform the present study, it will only be discussed briefly. Deterrents to participation are viewed as important in understanding involvement in adult education activities. As Scanlan and Darkenwald (1984) point out, "motivation orienta-tion factors have not proved useful in distinguishing participants from non-participants" (p. 155). Deterrents to participation provide some insight into distinguishing the two groups. In this study, the effect of participants' motivational orientations for participation on application of learning are of interest. As such, non participants do not inform this study. Although participants can choose to apply what has been learned, non-participants cannot apply something if it has not been learned. Therefore, deterrents to participation will not be addressed further. This review will be limited to motivational orientations influencing participation, that is, examining the relationship between reasons for participation and subsequent application of learning. Participation in Continuing Professional Education Literature concerning participation in CPE also informs this study. This literature addresses a specific component of adult education, involving a population of individuals similar to the present study. CPE differs from adult education in a number of ways; the content of the programs, the participants, and the voluntary or non-voluntary nature of participation. Participation in CPE is not always voluntary. Many professional associations 13 have mandatory CPE programs in place as a means for maintaining professional status and re-licensure within a profession. In addition, CPE is perceived by professionals and the public as an inherent part of being a professional. It is viewed as a method of assurance that professionals are up-to-date with current technology and advances. Continuing one's education is a lifelong responsibility of professionals and is necessary for maintaining and updating skills. Therefore, it is prudent to examine the literature regarding participation in CPE to determine if professionals' reasons for participation vary from the general population of adult learners. This review highlights similarities between the CPE participation literature and the adult education literature. In addition, the literature review examines differences in reasons for participation among health care professional groups. Comparisons in the CPE literature are made with the six groupings of motivational orientations as identified by the EPS (Boshier & Collins, 1985). The literature concerning participation in CPE is not as extensive as participation literature in adult education and the majority of research is limited to the health care fields (predominantly nursing and medicine). Use of the EPS or a modified version of it has been the basis for the majority of studies examined (Mergener, 1981; Mergener & Weinswig, 1979; O'Connor, 1979, 1982; Scanlan & Darkenwald, 1985; Thomas, 1986; Urbano et al., 1988). The purpose of the CPE participation research is similar to the purpose of the research done with adult education. That is, to use empirical methods to identify and organize the reasons for participation in CPE. Some researchers have also investigated the relationship between demographic/socio-economic characteristics and reasons for participation in CPE (Dolphin, 1983; Hanson & DeMuth, 1991; Mergener & Weinswig, 1979; Scanlan & Darkenwald, 1985; Thomas, 1986). This information is helpful for planning, implementing and evaluating programs. Investigations concerning the effect of mandatory CPE on professionals' motivations for participating in CPE has also been a driving force for research on reasons for participation. Researchers are interested in non- voluntary participation. This has been investigated by examining if motivational orientations and choice of attending CPE programs are influenced by the external factor of mandatory CPE requirements for re-licensure (Hanson & Demuth, 1991; Mergener, 1981; Mergener and Weinswig, 1979; O'Connor, 1979, 1982; Thomas, 1986; Urbano et al., 1988). Reasons for Participation in CPE Health care professionals participate in CPE for reasons similar to those found in adult education. Research results demonstrating this finding have been summarized in Table 1. Each study was individually analyzed to identify motivational orientations, instruments used, and the health care professional group studied. / Examination of the mean scores attributed to each motivational orientation revealed that cognitive interest, community service, and professional advancement scored the highest in the majority of cases. It can be concluded that most professionals participate in CPE for reasons related to their professional practice or area of work. The motivational orientations represented by external expectations, social contact and social stimulation play a lesser role in motivating professionals to participate in CPE (Cervero, 1981; Dolphin, 1983; Hanson & DeMuth, 1991; Mergener & Weinswig, 1979; O'Connor, 1979, 1982; Richards & Cohen, 1980; Scanlan & Darkenwald, 1985; Thomas, 1986; Urbano et al., 1988; Waddell, 1993). A sampling of the results from the studies cited above follows. O'Connor (1979) sampled 843 practising nurses who had attended formal continuing education programs in + + * * * s > r. 2. =•  t? ? g. B ^ — a m  c » ST 3 « tr < o *T3 R' 2 3 * sra*g M . £T » g S3 >< S o a. c o en B to re a g 3 S | B s s ? 8- S & . «3 5 o\ p £ . B 2 g cr. "o 2 II"! § g i ' g C U T S & ST 8 cr. — o o H 5. 8 §.'8. 3 o " 8 o .8 g. <S. c §•£ " 5" u> o c o 3 a o 2 c IS C a-v o o o o o oo lOV X x X X X X X X X x X X X X X X x x x s s 00 = X X X z c z e 8 a <> o X X X X X X X X X X X X X X X X X X X X X X X 2 2. 3° X X X X X X X X X X X Professional Advancement Social Stimulation External Expectations Social Contact Cognitive Interest Community Service X X X X X EPS (Boshier 1982) Participation Reasons Scale Modified EPS Own Instrument Learning Orientation Index Index of Continuing Educ. Participation 2 & F. o " S . Professional Group o H N H < > O Z > r o > H o z z H 51 C/5 a ffl O ST 16 various states in the United States. A modified version of Boshier's EPS was used to determine that nurses participate in CPE primarily for professional reasons. It was found that the motivational orientations described as cognitive interest, professional advancement, and community service exerted the most influence on participation. Waddell (1993) conducted a meta-analysis of the literature from 1972 to 1990 and concluded that motivational orientations explained 46% of the variance in participation. This finding demonstrates the influence of motivational orientations as a primary factor in deciding to participate in CPE. Of the motivational orientations, she concluded that external expecta-tions and cognitive interest exerted the greatest influence, followed by community service and professional advancement. Reasons associated with social contact and social stimulation were described as having less of an influence on participation. Scanlan and Darkenwald (1985) obtained supporting results with three groups of allied health professionals (physical therapists, respiratory therapists, and medical technologists). Thus, the results are not unique to nursing professionals. Using a modified, short form of the EPS and factor analysis techniques, they found that cognitive interest, professional advancement, and community service were the primary motivational orientations for participation in CPE. Differences were noted by Scanlan and Darkenwald (1985) between the three allied health professional groups. Respiratory therapists described reasons associated with external expectations, professional advancement, and social stimulation as having a greater influence than physical therapists did. In turn, physical therapists described the reasons associated with community service as having a greater influence on participation than the respiratory therapists and medical technologists did. These differences could be attributed to the greater 17 community service orientation of the profession of physical therapy (i.e., more community practices versus hospital based practice of the other two professions). Despite the differences noted between the allied health professionals, similarities on the mean scores of the motivational orientations were noted with the results obtained for nurses. Cognitive interest, professional advancement and community service orientations were the most influential factors in contributing to participants' decisions to participate in CPE. Research conducted on the reasons for participation of physicians in continuing medical education (CME) also supports the above findings. Richards and Cohen (1980) conducted a literature review of physicians' reasons for attending CME and five categories were identified. The five categories identified by Richards and Cohen are as follows: (a) participation as a part of professionalism, (b) interest in subjects related to medicine and medical practice, (c) validation of prior learning, (d) attaining objectives involving specific questions related to patient care, and (e) change of pace. The reasons for participation grouped in these categories are similar to the reasons associated with the motivational orientations identified by Boshier and Collins (1985). Motivational orientations most influential to motivate physicians' participation in CME were also determined by Cervero (1981). A factor analysis of the Participation Reasons Scale (PRS) developed by A.D. Grotelueschen and colleagues at the University of Illinois College of Education (1979) was used. Cervero (1981) found that reasons directly related to patient care were the most important motivational factors identified by physicians participating in CME. The two reasons given were: (a) to maintain and improve professional competence and service to patients and (b) to interact with colleagues. These two reasons are similar to Boshier's and Collins' (1985) cognitive interest and social contact 18 orientations except that the orientations of social contact and interacting with colleagues are defined slightly differently. Using the PRS, Cervero (1981) defines interacting with colleagues as relating ideas to professional peers, learning from interaction with professionals, exchanging thoughts with medical colleagues, maintaining identity with one's profession and being challenged by thinking with colleagues. In contrast, Boshier and Collins define the social contact orientation as improving interpersonal skills, meeting people, and making new friends. Thus, the PRS provides for a more practice-related and improving-practice orientation which is more fitting with Boshier's and Collins' professional advance-ment orientation. The findings demonstrated in the CPE literature are in keeping with the findings in the adult education literature. Job related reasons and personal development/general interest reasons were the most common reasons cited for participating in adult education programs (Carp, Peterson & Roelfs, 1974; Darkenwald & Merriam, 1982; Henry & Basile, 1994; Statistics Canada Survey, 1984). Reasons for participation most often cited are associated with three motivational orientations: cognitive interest, community service, and professional advancement. These three motivational orientations can be viewed as practice-related reasons for participating in CPE because they are factors which are associated with one's professional practice. Therefore, the most influential motivational orientations for participation in CPE are similar to those that influence participation in general adult education programs. Urbano et al. (1988) notes this by stating that "while motivational orientations vary slightly from study to study, they show consistency across countries, samples, and time" (p. 39). 19 Influences on Reasons for Participating in CPE Motivational orientations do not influence participation in a vacuum. As noted earlier, reasons for participation are only one of the antecedents to participation. Other antecedents to participation include desire, intention, attitudes, beliefs, demographic and socio-economic factors and lastly, external forces such as mandatory CPE. These antecedents work together and influence reasons for participation and participation as a whole. It is generally accepted that age and level of educational attainment do influence participation. The influence of demographic and socioeconomic factors have been investigated as have the effects of mandatory CPE. These two areas which influence reasons for participation will be addressed. Demographic influences. Demographic characteristics (i.e., age, employment status, place of employment, years employed, educational attainment, employment level/management) influence reasons for participation. Their degree of influence varies between and across professional groups. Both Dolphin (1983) and Thomas (1986) found that age and employment status of nurses are significantly related to motivational orientations/-reasons for participation. Thomas found that age was related to the social contact, social stimulation, cognitive interest, and professional advancement orientations. It was also found that employment status was related to cognitive interest, external expectations, and professional advancement orientations influencing participation in CPE. Dolphin found similar results in terms of age, length of time as a professional, and place of employment. These factors were related to professional advancement, social contact and social stimulation, and external expectations respectively. Dolphin also found that education level was related to external expectations and cognitive interest. Despite the similarities in the results, it is difficult to compare the findings associated with employment. Employment status was not defined in the investigation by Thomas (1986). 20 It is not known what is meant by employment status; is it the length of time as a professional, place of employment or simply fulltime or part time employment? Although these two researchers demonstrate that a relationship exists, the direction of that relationship remains unclear. We can assume the direction based on other studies done with different professional groups, but the researchers have neglected to inform the reader of the specific results. One study which does inform the reader of the direction of the influence is the investigation previously noted by Scanlan and Darkenwald (1985). The authors demonstrate that age, professional responsibilities and level of educational attainment are related to the influence of motivational orientations on participation. As these three factors increase, the professional advancement and external expectations orientations have less of an influence on participation, while social stimulation has a greater influence on participation in CPE. In conclusion, it has been demonstrated that age, educational level and employment characteristics are related to motivational orientations. Also of note is that differences are apparent between professional groups. The results may differ for the various professional groups for two reasons. One reason being the inherent differences in the type of people who choose to work in a specific profession. The second reason is that the nature of the work within the various professions could influence the reasons for participating. The influence of mandatory CPE. The implementation of mandatory CPE requirements for re-licensure or re-certification has led many investigators to question its effect on participation and reasons for participation. Mandatory CPE is viewed as a reason for participation within the external expectations orientation. Mandatory CPE is usually monitored by professional associations and is often based upon a credit per hour system. A certain number of credit hours are required for a specified period of time. Credit hours are 21 obtained by professionals through participation in educational programs. There is concern that participation in CPE programs may be chosen based upon the number of credit hours that will be obtained rather than for the content and potential benefits of enhanced professional practice. Hence, length of programs may be more of a deciding factor than the actual content and learning opportunities available. For this reason the effects of mandatory CPE on reasons for participation have been investigated. Thomas (1986) and O'Connor (1979, 1982) used a modified version of the EPS and factor analysis to assess reasons for participation among practising nurses in states where mandatory CPE was legislated. The influence of the mandatory requirement for participating in CPE was assessed as a motivation for nurses to participate. Despite this, the group of reasons identified under the external expectation orientation were not identified as the primary motivational orientation influencing participation. The cognitive interest orientation received the highest mean score, with the professional advancement orientation receiving the second highest mean score. Urbano et al. (1988) found similar results using the EPS and factor analysis. Cognitive interest, professional advancement and community service orientations were ranked significantly higher than the other three orientations (external expectations, social contact, and social stimulation). Although the above studies support the findings noted for health care professionals (refer to Table 1), Hanson and DeMuth (1991), Mergener (1981) and Mergener and Weinswig (1979) obtained slightly different results for practising pharmacists. Mergener and Mergener and Weinswig used a modified version of the EPS and factor analysis to carry out two investigations involving three groups of practising pharmacists. The three groups were as follows: (a) practising in states with legislated CPE, (b) practising in states that are in the process of legislating CPE, and (c) practising in states without legislated CPE. Competency-22 related curiosity (similar to cognitive interest) was rated as the highest motivational orientation for all three groups. This result reflects the findings of other researchers involving different health care professional groups. The first investigation (Mergener & Weinswig, 1979) revealed a difference with the motivational orientation ranked the second highest. The group with legislated CPE ranked the reasons for participation associated with compliance with external influence the second highest; the other two groups ranked the reasons associated with community service as the second highest followed by external expectations. A follow-up study done by one of the authors (Mergener, 1981) confirmed the earlier findings of the effect of mandatory CPE on motivational orientations for participation. It was found that the group in the process of legislating CPE ranked their reasons for participating differently after having mandatory CPE in place for two years. Reasons associated with compliance with external influence were ranked significantly higher at the expense of reasons associated with professional advancement. The other two groups did not rank the reasons for participation significantly different. It can be concluded that the presence of mandatory CPE influences pharmacists' reasons for participation in CPE based upon the value placed upon the motivational orientation of external expectations. Hanson's and Demuth's (1991) investigation of facilitators and barriers to pharmacists' participation in lifelong learning revealed similar results. Pharmacists residing in states with mandatory CPE rated the requirement for maintenance of professional licensure, an external influence, second highest following cognitive interest, when rating the reasons for participating in CPE. The authors developed two instruments to identify both potential facilitators and barriers to learning using a seven-point Likert scale. Descriptive statistics (mean scores) were used to present the results. The difference noted in the reported 23 reasons for participation could be a result of using a different instrument to measure the variables under study. Despite the use of a different instrument, Hanson's and DeMuth's results are similar to the results obtained by Mergener (1981) and Mergener and Weinswig (1979). The differences noted in motivational orientations in the presence of mandatory CPE could be attributed to differences of professional nature. Only the investigations involving pharmacists demonstrated the influence of external expectations on participation. Limitations of Existing Research on Reasons for Participation in CPE All of the researchers have employed survey methods. Mailed surveys, administered to practising health care professionals such as doctors, nurses, and pharmacists, have made up the bulk of the sample populations. One study surveyed physical therapists, respiratory therapists and medical technologists. A limited representation of health care professionals is in evidence. Although the researchers found similar results for health care professionals' reasons for participation, it should be noted that all of the studies involved survey research measuring self-reported claims by respondents answering in a socially responsible manner or with what they thought the researcher wanted to hear. This could be one explanation for some of the differences noted in responses between the groups of health care professionals. The limits of self-reporting apply to all the studies reviewed. Although the limitations cannot be overcome given the type of data being collected, it must be recognized as a limita-tion. Obtaining self-reports from the professionals is the only way to obtain information regarding individual motivational orientations. Another limitation of the research done concerning reasons for participation is that of volunteer or response bias. The results are only representative of those individuals who chose 24 to respond to the survey. Had the non-responders provided data, it may have been a significantly different representation of reasons for participation. Only one study (Urbano et al., 1988) sampled the non-responders and included this data in the investigation. In all other cases the responses of the non-responders were unknown. In all cases the characteristics of the respondents are described in detail. These descriptions can be used by other researchers as a comparison to their sample populations. In most cases the response rate was adequate. A response rate of over 50% was reached for 6 out of the 9 studies examined. A response rate of at least 70% is required in order to assume that the non-responders will not affect the results (Schumacher & McMillan, 1993). Lastly, the use of different instruments and forms of an instrument (e.g., a modified version of the EPS) could account for some of the differences in reports of reasons for participation. The use of different instruments or modified instruments may have resulted in the researchers measuring slightly different constructs of reasons for participation. Summary of Research on Reasons for Participation in CPE It is concluded from this review that similar reasons for participation influence the various health care professionals in deciding to participate in CPE. This review of the reasons for participation in CPE was based upon research involving motivation theory. Reasons for participation identified by health care professionals were explored by using the EPS and other instruments. It was found that health care professionals participate in CPE primarily for reasons related to their professional practice and professional interests. These reasons are: professional advancement, cognitive interest, and commumty interest. Factors such as age, educational level and employment characteristics are related to motivational orientations. When external influences such as mandatory requirements for participating in 25 CPE are present, nurses' reasons for participation were not altered. Pharmacists' reasons for participation did change with the presence of external influences. It was demonstrated that mandatory CPE was a strong influence on pharmacists' reasons for participation. Evaluation of CPE The preceding literature review focused on the antecedents to CPE. The literature review now turns to the outcomes of CPE. The evaluation literature of CPE programs addresses the outcomes of participation in CPE, including professional performance. The need for accountability drives this literature. Evaluation studies help justify the premise of mandatory CPE programs, i.e., that mandatory CPE programs ensure competency and state of the art practices. These studies measure program outcomes, participation, and learning. There are many possible outcomes of CPE. Outcomes could be related to the program, the participant (the professional) or to the public whom the professionals serve. Outcomes directly related to the participant and the program are as follows: satisfaction with the program, the instruction and instructor; a change in knowledge, way of thinking or skill level; and a change in behaviour or practice (application of learning). Outcomes directly related to patients or clients are changes that can be observed by improved client or patient well-being. Cervero (1988) identifies seven categories of evaluations which address the outcomes as identified above. The categories are: (a) program design and implementation, (b) learner participation, (c) learner satisfaction, (d) learner knowledge, (e) skills and attitudes, (f) application of learning after the program, and (g) impact of application of learning. Application of learning is the outcome of interest for this study and the literature on evaluation of CPE has been reviewed with this focus in mind. 26 Application of learning can be assessed by surveying the participants, their peers, employers or superiors, or the clients/patients whom the professionals serve. The outcomes could also be assessed through observation during practice or through document analysis (of patient or office records). Cervero (1988) cautions about the appropriateness of attempting to measure the outcome of application of learning, for all programs: "the educational intervention must be powerful enough to produce a change in professional performance...Program planners often have unrealistically high expectations in terms of what is achievable, especially for short-term programs. Unless a clear case can be made for probable impact, it is a waste of valuable resources to ask evaluation questions related to the application of learning" (p. 142-143). One must keep this in mind when reviewing evaluation studies. Furthermore it should be noted that application of learning is not an appropriate outcome measure in all instances. There is extensive literature available on evaluation studies of CPE and CME as well as reviews of the literature. Despite the number of studies done and improvements made in methodologies, inconsistent results plague the literature. One blaring gap remains apparent; the link between the conditions prior to the CPE program and the subsequent outcome that is being measured. There has been no connection made between reasons for participation and the outcomes of participation in CPE. The evaluation literature will be reviewed by present-ing the various levels of evaluation and the evolution of evaluation procedures. Evaluation research has evolved from measures of satisfaction to knowledge gains, to behaviour changes and application of learning, to measuring the impact of learning on patient care (Abraha-mson, 1968). It will be demonstrated that there are other factors in addition to the CPE program that are responsible for the outcome, i.e., application of learning. 27 An Evolution of Evaluation Research As first described by Abrahamson (1968), an evolution of evaluation procedures can be seen by reviewing both empirical research and extensive literature reviews. Abrahamson outlines four types of CPE evaluations: satisfaction evaluations, evaluation of knowledge or skill changes, evaluation of performance changes, and outcome evaluations of practice. Satisfaction evaluations. Early evaluations focused on participants' attitudes and degree of satisfaction with the program, the content, and/or the instructor as outcome measures. These evaluations are nicknamed 'happiness indexes.' Published investigations using this type of evaluation are becoming less common, although this remains the most commonly practised evaluation. In reviewing the literature concerning evaluation of the effectiveness of CME, Davis et al. (1984) found 20% (35 out of 170) of the studies used only a 'happiness index' as a measure of the effectiveness of CME. This number has decreased dramatically as seen by Turnbull and Holt's (1993) review of the evaluation litera-ture. Their review focused on the effectiveness of allied health CPE in the past 20 years. Only 5% of the studies (1 out of 20) looked solely at satisfaction as a measure of the effectiveness of CPE. This indicates the decreased use or publication of this type of evaluation method because it provides minimal insight, if any, into what or how much was actually learned. Furthermore, these types of evaluations ignore the effects of CPE programs on professional practice. Knowledge or skill change. Evaluations measuring changes in knowledge base or skill level were implemented when evaluators began to realize that satisfaction measures provided little insight into the effectiveness of programs. These types of evaluations measure knowledge or skill before and after the CPE program. They provide an indication of what was learned at the CPE program. For example, Geissinger, Humphry, Hanft and Keyes 28 (1993) demonstrated a change in occupational therapists' and occupational therapy assistants' attitudes towards family-centred care following participation in a three-day workshop. Some problems were noted with the design of this study. Firstly, a control group was not used therefore the results cannot be conclusive. Secondly, factors other than the workshop could have influenced the change in attitude measured. Examples of such factors are the possible effects of administering the pre-test and post-test. This alone could result in an apparent change in attitudes. Also the different instructors used in the workshops could have confounded the results. As seen by the study done by Geissinger et al. (1993), an evaluation of skill or behaviour change provides information about what was learned and applied. The short coming is that it tells us nothing about the effects of the CPE program on the practice of professionals or on the subsequent patient outcomes. We know that there was a change in attitude but we do not know how this change in attitude has impacted on the professionals' practice. Despite the minimal information and limited significance of the information provided by this type of evaluation, Turnbull and Holt (1993) found 35% (7 out of 20) of the studies examined used this evaluation method. Performance changes. The evaluation of changes in performance or practice following CPE goes one step beyond changes in knowledge and skill. These types of evaluations look at the impact of knowledge or skill change on a professional's performance. Numerous studies have measured changes in practice following CPE. These studies have demonstrated that CPE may result in positive changes in behaviour in some situations (Caplan, 1976; Chambers, Hamilton, McCormick & Swendeman 1976; Cox & Baker, 1981; Sparks, 1988; Wergin, Mazmanian, Miller, Papp & Williams 1988). 29 Chambers et al. (1976) used a combination of observation and questionnaires to assess changes in dentists' practices. The investigators observed dentists in practice before and after attending a one-day CPE workshop and administered a questionnaire (self-report) following the workshop. The authors found that the workshop did result in observable behaviour change. The small sample size (n = 15) does introduce a limitation to the study design. Because observations were done pre and post workshop, the number of subjects was minimized to provide for a manageable data collection procedure. This is one reason that observations are not often used to conduct evaluations. Observations are time consuming and expensive. It is much easier and less expensive to reach large numbers of subjects through the use of mailed surveys. But, the use of mailed surveys introduces another limitation, self-reported data. Evaluations measuring changes in performance are of greater significance because they provide evidence of application of learning. But as previously mentioned, not all CPE programs are planned or intended to provide sufficient learning opportunities to facilitate application of learning. In all of the above noted studies, the type of CPE program evaluated was conducive to encouraging application of learning and positive changes were demonstrated. Patient outcomes. The last type of evaluation is concerned with the effects of CPE on patient care. Very few evaluation studies have been done at this level. This is largely due the expense and the complexity of conducting such evaluations. Despite the apparent lack in the earlier literature, the number of studies which have addressed patient outcomes as a result of improved performance from CPE has been increasing over the years. Four large-scale literature reviews demonstrate the change from the 1980s to the 1990s. A review of the literature conducted by Haynes, Davis, McKibbon and Tugwell (1984) identified only three 30 articles (1 %) demonstrating improved patient outcome as a result of CME. Additional literature reviews done in the 1980s indicate similar findings. Abrahamson (1984) and Nona, Kenny and Johnson (1988) both identified six articles (7% and 4% respectively) that indi-cated improved patient outcome as a result of CME. A large increase in the number of evaluations addressing patient outcomes was noted in the literature review conducted by McLaughlin and Donaldson (1991). The authors found that 62% of the articles reviewed evaluated patient outcomes. The increase in this type of evaluation indicates an increased interest in accountability for professional practice and CPE. It also indicates an improvement in evaluation methods and conceptions. The investigations involving evaluation of patient outcomes related to participating in CPE demonstrated improved patient outcomes. It is important to note that many variables are responsible for quality of professional practice and patient outcomes, not just the CPE program (Inui, Yourtee & Williamson, 1976; Peden, Rose & Smith, 1992; Williamson, Aronovitch & Simonson, 1975). The studies mentioned above attribute the change in patient outcomes solely to the CPE program. Many other factors, situational and personal, have an influence on patient outcomes, not just health care professionals, and the extent of their CPE activities. Summary of Evaluation Research in CPE According to Cervero's theoretical framework (1985), situational factors, personal characteristics and the CPE program itself contribute to changes and improvements in practice. Evaluation studies that credit improvements or changes in practice to solely the educational program are limited in vision. This approach does not fully inform educational practice. Two questions remain unanswered. The first question is why are some CPE 31 programs effective, while others are not? The second question is why do some learners apply what they learn and subsequently change their practice, while others do not? Examining situational factors and personal characteristics can help to better inform educational practice by understanding application of learning. Evaluations of the efficacy of Cervero's framework for assessing the effectiveness of CPE have demonstrated its usefulness (Cervero & Rottet, 1985; Peden et al., 1992; Wergin et al., 1988). A subsequent evaluation by Cervero, Rottet and Dimmock, (1986) confirmed their earlier findings of the usefulness of the framework by expanding upon quantitative data with qualitative data. It is apparent that many variables play a role in the outcome of CPE. Antecedents to the CPE program and the situational aspects of the workplace must be considered in the evaluation process. Consulting the literature available on transfer of learning brings further insight into this issue. Transfer of Learning The transfer of learning literature is one area where some attempt has been made to link antecedents of participation with the outcomes of training. Through a review of this literature, the link is examined. Acquiring a better understanding of the transfer of learning process will help to explain why some educational/training programs are successful and result in transfer of learning while others do not. There is an increasing amount of evaluation research concerning the effectiveness of CPE programs and training programs. This is indicative of a growing interest in understanding the transfer of learning process. 32 Transfer of learning has been defined as the extent to which knowledge, skills and attitudes that are acquired from an educational program are subsequently used in one's practice or work setting (Ford, 1994). According to Cafferella (1994) and others, six factors are involved in the transfer of learning process. Depending upon the situation, each of the factors can act as either enhancers or barriers to transfer of learning. The six factors are: (a) the program participants, (b) program design and execution, (c) program content, (d) changes required to apply learning, (e) organizational context, and (f) community/societal forces. Program participants and their characteristics are central to all training situations and are consistent across different programs. Individual characteristics that remain constant are values, beliefs, and attitudes towards education and training. It is essential that the learner's characteristics, prior to participation in the training program, are considered as an integral part of the transfer process. Several authors in the training literature suggest that a better understanding of participants' training-related motivation is essential for conceptualizing training effectiveness (Mathieu, Tannenbaum, & Salas, 1992; Noe, 1986; Wexley & Latham, 1991 cited in Tannenbaum & Yukl, 1992). Investigators suggest that motivation is the force that influences enthusiasm, directs participation and influences the use of newly acquired knowledge in training situations. Unlike the CPE literature concerning health care professionals, the training literature in business and industry has attempted to connect participants' characteristics with the learning process and the educational outcome. The learners' characteristics (e.g. ability, motivation, and expectations) have been identified as an integral part of understanding the transfer of learning process (Baldwin & Ford, 1988; Katz, 1956; Michalik, 1981; Ottoson, 1994; Parry, 1990). Of interest to this 33 study is an understanding of the role that learners' motivation and reasons for participating play in the transfer process. The valence-instrumentality-expectancy (VIE) theory developed by Vroom (1964) has been useful in guiding most of the work done on understanding educational motivation (Baldwin & Ford, 1988; Howard, 1989; Mathieu, et al., 1992; Tarmenbaum, Mathieu, Salas & Cannon-Bowers, 1991). VIE theory states that the force of motivation (i.e., behaviour) is a product of the valence (perception of participation in training/education as a means of sat-isfying perceived needs), instrumentality (the subjective estimation of the likelihood that the behaviour as a result of the program will be rewarded), and expectancy (expectations about the results or outcomes of a learning activity). By using this approach, situational variables and variables associated with individual participants' expectations, motivation, and values are related to outcomes of training. Research has not provided conclusive evidence that supports the utility of VIE theory but the expectancy basis of motivation has been demonstrated. Participants with high levels of motivation learn more, are more likely to complete the training, and attempt some degree of application (Baldwin, Magjuka & Loher, 1991; Tarmenbaum, et al., 1991). This finding is in agreement with Howard's comprehensive expectancy motivation model (1989), which postulates that motivation must be present at the pre-learning, learning and post-learning stages in order for successful application of learning to occur. The key is enabling the learner to maintain a high level of motivation throughout the process. Hucyznski and Lewis (1980) inductively developed a model suggesting that one's motivation to transfer learning can be enhanced if one's decision to participate in training is voluntary or non-voluntary. Their investigation involved both qualitative and quantitative data collection techniques. Semi-structured interviews were used to supplement the data collected 34 through self-reported questionnaires. The investigators were able to demonstrate that pre-course characteristics and attitudes of the learners were related to application of learning four months following the training program. Others (Baldwin et al., 1991; Hicks & Klimoski, 1987) have since demonstrated similar findings; motivation to learn is enhanced by the trainee being able to choose the content of the training program. The investigators looked at reasons for participation and choice of attending a program and linked this to subsequent outcomes (Baldwin, et al., 1991; Hicks & Klimoski, 1987; Huczynski & Lewis, 1980). The conclusions reached indicate that the greater the choice given to the trainee, the greater the motivation and likelihood that learning will occur and will subsequently be applied on the job. Hicks and Klimoski compared the outcomes of training of four groups who were subjected to different entry conditions into training programs. Baldwin et al. compared the learning outcomes of three groups of learners (no choice in training, choice in training — but choice not received, and choice in training — choice received) in terms of learning outcomes. This literature introduces the concept of a relationship between voluntary participation and learning out-comes. Participants who voluntarily chose to participate in training programs demonstrated greater learning. The shortcomings of this research (Baldwin et al., 1991; Hicks & Klimoski, 1987) are that the long term effects of learning and possible transfer of learning were not addressed. The outcome measures of the training were done immediately following the training program. The various outcomes of the training that were measured were cognitive ability, motivation, and learning. Transfer of training was not specifically addressed as one of the outcomes, but was implied. Despite this, the investigations provide insight into the issue of 35 prior conditions to training programs and the effect on learning. Learning is a precursor to transfer of learning therefore these findings are of interest. Berger (1977) also investigated the training and transfer of learning process by examining it as a seven stage process. Stage one begins before the learning experience; it involves selecting an individual to attend a training program. Stage two is where the future participant is briefed about the training event. Stage three is when the participant develops attitudes and expectations about the future training program. The actual training and learning experience of the participant is stage four and stage is five is the subsequent attitudes of the participant toward transfer of learning and also involves the formulation of application of learning plans. Re-entry into the employment organization is stage six and stage seven is the transfer of learning. Berger found that attitudes and expectations were strongly related to transfer of learning. Although this work is not based directly on VIE theory, the results are similar to those obtained in the studies cited above which are based on VIE theory. This further substantiates the concept that learner motivation and expectations prior to par-ticipation are related to transfer of learning. Limitations of Research on Transfer of Learning In summary, the main limitations of the training research are related to the self-reported data. As previously discussed in this literature review, the self-reported data obtained by the subjects may be biased or not completely accurate. The subjects may respond with what they think the investigator wants to hear or with socially desirable responses. Also, by agreeing to take part in the study, the subjects bias the sample. The sample is considered to be volunteer biased because those who agree to participate in the research study may differ 36 in characteristics from those who chose not to participate. Consequently, the generalizability is limited to populations similar to the volunteers. Despite these limitations, this body of literature provides insight into the problem under investigation in this study. These investigations provide the only attempts made at linking antecedents of participation to outcomes of learning. Establishing the Link The work done in the training and transfer of learning literature informs the present study by demonstrating a relationship between the characteristics of participants and the outcomes of training. But, the present study is more specific in focus. Participants' motivational orientations or reasons for participation as antecedents to participation are of interest, as is the outcome, application of learning. As demonstrated in this review of the literature, there is a limited amount of research which has investigated the link between the antecedents to participation in educational programs and outcomes. Although it is not a missing link, it is surely a weak link. Consequently, the theoretical basis of this link is not well established. The learning process, starting with reasons for participation, can be viewed as a means to an end; the end being the outcome of application of learning. As shown in Figure 1, reasons for participation, the antecedents, are at one end and application of learning, the outcome, is at the other end. The middle ground connecting the two is the linkage. The linkage represents the relationship or association between the reasons for participation and application of learning. 37 participation/learning process reasons for participation (antecedents) (linkage) > application of learning (outcomes) Figure 1. Representation of the participation/learning process demonstrating the link between antecedents and outcomes. The literature supports the hypothesis of this study, a link between antecedents and outcomes. For example, Chambers et al., (1976) investigated the extent of the behaviour change of dentists as a result of continuing dental education. The authors found that dentists who participated in the course for the stated reason of considering a change and hoping to get more information about the anticipated change were identified as the 'big changers'. This means that they made the most changes in their practice as a result of attending the workshop. The authors concluded that the motives of practitioners could have been used to predict changes resulting from participating in the workshop. This study, although it is of limited validity due to the small sample size (n=15), suggests that voluntary reasons for participating could be of use in exploring application of learning. Antecedents to participation, at one end of the learning/ participation process, provide a starting point for studying the processes of participation, learning, and application. This study focuses on reasons for participation as the antecedents of interest. In the literature, reasons for participation have been explained by motivation theory. Numerous investigators have used Boshier's EPS and factor analysis to assess reasons for participation and explain Literature Review - Summary 38 participation using six motivational orientations. Similar reasons for participation were found with adults in general adult education programs and with professionals in CPE programs. This literature review reveals that similar motivational orientations influence adults in the decision to enrol and participate in educational programs. The most influential motivational orientations are cognitive interest, professional advancement and community service. Outcomes of participation, at the opposite end of the participation/learning process, help to complete the picture by laying a distant point for the process. A review of the evalu-ation literature reveals that various outcomes of participation have been assessed and measured. Application of learning is one of these outcomes. The transfer of training literature in business and industry lends further insight into the concept of application of learning. Some researchers in the area of business and industry have recognized the need to look at the relationship between antecedents to participation and outcomes. But as noted in the review, one limitation of this literature to the present study is that learning is the outcome that was most often addressed, not application of learning. As evidenced by this literature review, there are empirical studies investigating both ends of the process of participation/learning. An understanding of the linkage between the ends is missing. Hence, how the outcome is linked to antecedents of participation is one way in which to understand the entire process. Further research is needed to determine the extent of the relationship between antecedents to participation in CPE and subsequent behaviour in order to better understand this process. 39 Chapter Three Research Design This study involves analyses of data collected for a large scale evaluation of the Centre for Substance Abuse Protection (CSAP) Training System (CTS). The four-year evaluation began in 1991 with data collection commencing in the spring of 1993. The primary purpose of the evaluation study is to investigate the application of learning related to the CTS training workshops. The CTS offers 24 different types of training programs to professionals and volunteers who work in the area of substance abuse prevention and/or in health promotion. The interest of the present study is limited to continuing professional education. Therefore, only data obtained from training specifically offered for health care professionals is utilized. Seven different types of health care professional training programs were developed. Most consisted of one-day workshops, with curriculum targeted to different professional audiences. Curricula were developed for dentists, physicians, nurses, primary care clinicians, mental health counsellors, social workers and rehabilitation specialists. Although the specific content of each type of training differed, all intended to engage health care professionals in preventing substance abuse among their clients or more broadly in the community. One component of the evaluation process in the CSAP investigation used survey research to obtain self-reported responses from health care professionals. An intact group (non-random sample) of volunteer subjects was used for the study. A control group was not available. All participants of the CSAP Training System (CTS) workshops were asked to participate in the study by completing three questionnaires. A Participant Profile 40 Questionnaire was administered before the workshop; a Participant Feedback Questionnaire was administered immediately after the workshop; and a Foliow-Up Questionnaire was administered two to four months following the CTS training workshop. In all cases of questionnaire distribution confidentiality and/or anonymity was assured. No exclusion criteria were utilized other than ensuring that only matched responses of the respondents, tracked over time, would be used for subsequent data analyses. Matched respondents are those respondents who completed all three questionnaires (Participant Profile, Participant Feedback and Folio w-Up). They were matched anonymously by participant codes. Subjects Health care professionals who attended the CTS training workshops are the population from which the study sample was chosen. The parameters set in choosing the subjects for this study were as follows: (a) health care professionals, (b) those training workshops with the largest numbers of participants, and (c) the health care professional groups with the highest percentage of matched (at pre, post, and follow-up) responses. The groups with the largest response rates of matched data were chosen in order to provide the largest possible sample size, thus maximizing the potential statistical power of the analyses. Table 2 presents a summary of the response rates for all of the health care professional groups who participated in the CTS training workshops. The complete data log for all the health care professional groups is in Appendix A. Four groups representing different health care professionals were chosen based upon the above the criteria: nurses, mental health counsellors, physicians, and rehabilitation specialists who participated in the CTS Training Workshops in 1994. The four different health care professional groups allow for a varied representation of the broader group of 41 health care professionals attending the CTS workshops. All subjects responded to the three questionnaires and were matched anonymously by participant codes. Table 2. Summary of Response Rates for CTS Training Evaluations Group Pre Post Number Follow-Up Matched Percent Dentists 57 38 12 9 18 Physicians 111 96 45 36 32.7 Nurses 734 713 202 129 18.4 Primary Care Clinicians 64 52 11 10 15.6 Mental Health Counsellors 426 400 127 80 19.3 Social Workers 72 55 15 13 18.1 Rehabil-itation Specialists 161 144 41 34 21.7 Note. Pre = Participant Profile Questionnaire; Post = Participant Feedback Questionnaire; Foliow-Up = Follow-Up Questionnaire; Number Matched = number of respondents whose questionnaires matched anonymously at Pre, Post, and Follow-Up by respondent codes; and Percent Matched = percent of respondents whose questionnaires matched anonymously at Pre, Post, and Follow-Up by respondent codes. 42 Instrumentation The questionnaires used to collect the data for this study were developed by a team of researchers and contractors involved in the CSAP investigation and the CTS training workshops. Three questionnaires were used to collect data at different stages of the investigation and utilized a pre, post and follow-up format. The three questionnaires are as follows: (a) Participant Profile Questionnaire, (b) Participant Feed-Back Questionnaire, and (c) Follow-Up Questionnaire. The questionnaires were based upon a conceptual framework of the application process developed by the CSAP investigators (Ottoson, in press). A diagram representing the conceptual framework is in Appendix B. The predisposing and contextual factors in the framework posit influences on application suggested previously in the literature review, i.e., characteristics of the education program, predisposition of the learner including reasons for participation, and enabling and reinforcing characteristics of the context of application. This study focuses on the predisposing factors of the application process. Two of the three questionnaires used in the large scale study served as the instruments used to collect the data for the independent and dependent variables that were analyzed in this study. The Participant Profile Questionnaire and the Follow-up Questionnaire contain the questions pertaining to these variables. The Participant Profile and Feedback questionnaires contain variables used to determine the response bias of the study sample. Samples of all three questionnaires are included in Appendix C. Independent Variable The independent variable, reasons for participation, is concerned with influences on participants to attend CTS training workshops. Reasons for participation are questions 2a - e on the Participant Profile Questionnaire: 4 3 Independent Variable - Reasons for Participation (a) general interest, (b) need to do your job or volunteer activities differently, (c) required by organization to participate, (d) confirm what you are already doing is O.K., and (e) chance to network with others. Reasons for participation, included in the predisposing factors of the conceptual framework, are suggested to influence application of learning and are the independent variable in this investigation. As demonstrated previously in the literature review, reasons for participation are one of the many antecedents to participation. Reasons for participation provide an explanation, using motivation theory, of why adults participate in adult education programs. This study attempts to demonstrate a linkage between antecedents to participation and application of learning. Therefore, it is hypothesized that reasons for participation are related to application of learning. The response categories for reasons for participation reflect a sampling of common reasons cited by adults for participating in adult education and CPE (Boshier, 1971; Cervero, 1981; O'Connor, 1979; Scanlan & Darkenwald, 1985). Six motivational orientations are commonly used to explain reasons for participation in adult education and CPE including: professional advancement, social stimulation, external expectations, social contact, cognitive interest, and community service. The reasons used on the Participant Profile Questionnaire represent a sampling of these categories (e.g., general interest falls under cognitive interest and required by organization to participate falls under external expectations). Each reason for participation category is measured on a scale of 1 (no influence) to 5 (extremely influential). 4 4 For the purposes of this study the independent variable has been divided into two groupings; voluntary and non-voluntary reasons for participation. The voluntary reasons for participation are 'need to do things differently', 'confirm what you are already doing is O.K.', 'chance to network with others' and 'general interest'. These reasons are related to meeting individual and work-related needs, i.e., ensuring that the way in which one is practising is in agreement with the way others in similar positions are practising or expanding upon ones' knowledge and understanding about current practices. General interest, as a reason for participation may be related to one's general interest in their job but may also be related to one's personal or family interests. In addition to being related to individual needs, these reasons for participation represent voluntary actions on behalf of the participant. The non-voluntary reason for participation represented in this investigation is 'required by organization to participate'. Required by one's organization to participate is indicative of an external or non-voluntary influence. This reason implies that meeting individual or work-related needs are not a primary reason for participating, but rather, participation is a requirement established by someone else. In this case, the motivation to participate is due to external influences and the participation is non-voluntary. Dependent Variable Application of learning is the dependent variable utilized in this study. The dependent variable is defined as job/practice related changes that participants made at their respective work-sites following participation in the CTS training workshop. The variable is identified on the Follow-Up Questionnaire (questions # 5b and 5g). The two indicators of application of learning include: 45 Dependent Variable - Application of Learning (a) made changes in how you do your work or volunteer activities (question # 5b) and (b) increased substance abuse prevention activities (question # 5g). A third indicator of application of learning on the Follow-Up Questionnaire (question # 6 -To what extent did you do the following as a result of the workshop?) was not used in the data analyses as it is similar to question # 5b. In addition, the responses to questions # 6 and 5b for the sample population were significantly correlated (r = 0.814, p_ < .01), indicating that they are similar questions. The two indicators of application of learning reflect different modes of application of learning to the practice setting that can be rated by the participants and are observable. Application of learning must be measurable and objectified in behavioural terms (Cervero, 1988). The two indicators of application of learning were rated by the participants using a scale of 1 (not at all) to 5 (substantial). Application of learning is a possible and intended outcome of learning from the CTS workshops. As noted in the literature review, possible outcomes include participant satisfaction, a change in cognitive or affective knowledge and/or a change in motor skill ability, application of learning, and lastly, improved client or patient well being. Instrument Reliability and Validity The questionnaires used to collect the data were determined to be valid for use based upon evidence obtained through examining the construct, content and face validity. Construct validity. The construction of the three questionnaires used in this study was based upon a conceptual framework (Ottoson, in press) which suggests that educational 46 process and content factors influence predisposing and contextual factors (enabling and reinforcing) which, in turn, influence the application of learning and subsequent impact. (Refer to Appendix B for a diagram of the Application Process Framework.) The theoretical basis of this framework was informed by models used in adult education, health education/promotion and decision-making. The respective models used in developing the conceptual framework are the Cervero Model (Cervero & Rottet, 1984), the PRECEDE/PROCEED Model (Green & Kreuter, 1991), the Concerns-Based Adoption model (Hall, 1979), and the stages of the innovation-decision process (Rogers, 1983). Each of the questionnaire variables are matched to a specific factor of the conceptual framework. As such, the variables represented on the questionnaires are grounded in theory and construct validity is established. Content and face validity. The content and face validity evidence of the questionnaires were assessed and determined to be representative of the construct being measured. This was done by examining the literature; consulting an expert community panel, a technical advisory panel, and CTS contractors and trainers; and through the use of focus groups and pilot tests with health care professionals and community groups. A consensus regarding the appropriateness, accuracy and representativeness of the measures of the application process was reached. Thus, the content and face validity of the instruments were established. Reliability. Reliability measures such as test-retest stability and equivalency were not feasible as the subjects were only available for questionnaire adminstration at one time (during the CTS training). A variety of different groups were administered the questionnaires; thus requiring stability and equivalency measures be done for each group. This would have been very time consuming for such a large scale study. Using part of the 47 potential study sample to test the stability and equivalency of the instrument was not feasible. It would have resulted in a smaller sample on which to draw on for the study. Data Collection Procedures As noted above, the data that was utilized in this study was collected as part of a large scale national study sponsored by the CSAP. Instrument Adminstration The Participant Profile Questionnaire was distributed to all participants at the beginning of CTS workshops. A standardized presentation was made by the trainer at each workshop to introduce the participants to the evaluation. All participants were asked to complete the Participant Profile Questionnaire prior to the start of the workshops. The Participant Feedback Questionnaire was distributed just prior to completion of CTS workshops. All participants were requested to complete the questionnaire at that time. One of two procedures was used for administration of the Follow-Up Questionnaire. The Follow-Up Questionnaires were mailed two to four months following completion of the CTS workshops. All participants who did not respond to the initial mailing of the Follow-Up Questionnaire were mailed reminders to return their completed questionnaire. Coding Procedure for Individual Respondents The anonymity of respondents was a concern at all types of health professional training workshops. Different procedures were used to protect anonymity depending on the type of participants and training preference. Dentists and physicians pre-coded questionnaires with a confidential number that identifies the individual participant's responses on the three 48 stages of the questionnaires. Other groups allowed participants to generate their own anonymous codes. Coding was necessary in order to facilitate the matching of respondent data for the three questionnaires while preserving confidentiality. Anonymity and Confidentiality An ethics review process was established by the researchers and approved by the University of British Columbia Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects. Confidentiality was maintained by limiting access to respondent codes and contact information to the principle researchers. The Participant Profile and Feedback questionnaires were answered anonymously and participants were requested to complete a consent form indicating agreement of further participation in the study. Only those participants who signed the consent form had their participant contact information linked to their individual codes. This was necessary to facilitate the adminstration of the two to four month Follow-Up Questionnaire. Participants who generated their own codes could not be identified or traced. Procedure for Dealing with Response Bias The study participants are those individuals who answered the Participant Profile, Participant Feedback and Follow-Up questionnaires and were matched anonymously by participant selected code. In order to assess whether the study participants were representa-tive of the CTS workshop participants as a whole, the matched respondents were compared with those respondents who did not provide responses that could be matched for the Partici-pant Profile, Participant Feedback and Follow-Up questionnaires. The two groups were 49 compared on a select number of variables. Demonstrating representativeness helps increase the generalizability of the results to a larger group of health care professionals. The responses of the matched participants were compared to responses of unmatched participants on select situational variables. The selection process for the variables used for the comparison was informed by the literature (Baldwin, et al., 1991; Cafferella, 1994; Kemerer, 1991; Parry, 1990), current understanding of possible influences on application of learning, and the conceptual framework guiding the questionnaire design. The following situational variables were selected: Variables selected for comparison from the Participant Profile Questionnaire (a) informed about the purposes of the workshop, (b) previous training or education in substance abuse prevention, Variables selected for comparison from the Participant Feedback Questionnaire (c) usefulness of the workshop, (d) relevant to your job, (e) extent that sufficient resources exist in your organization to help apply your learning. Demographic variables such as ethnicity, age, gender and level of educational attainment were not included in this analysis as they will be summarized by descriptive statistics. A summary of the demographic profile of the population is needed for comparison purposes by future investigators. Data Analysis All statistical analyses were computed with the statistical program, SPSS (Statistical Program for The Social Sciences) version 6.1. The sample population consisted of four 50 health care professional groups. The data were treated as one large sample (n = 281) instead of four small samples (n = 34, n = 36, n = 80, and n = 129) allowing for greater statistical power. This was done despite preliminary data analysis which revealed that the four groups were significantly different in their mean responses for four of the seven variables under study. A series of one-way analysis of variance (one-way ANOVA) tests were used to compare the mean responses of each of the health care professional groups for each of the variables. Significant (p_ < .01) differences between the health care professional groups were noted for the variables 'need to do job or volunteer activities differently', 'general interest', 'required by organization to participate', and 'made changes in how you do your work or volunteer activities' (see Table 3). A Tukey's 'honestly significant difference' (HSD) procedure was used to determine which of the health care professional groups differed from each other in the statistically significant ANOVA tests. For the variable 'need to do job or volunteer activities differently', the physicians differed significantly (p_ = 0.0128) from the mental health counsellors in their responses. The physicians' and the rehabilitation specialists' responses were significantly different (p_ = 0.0029) from the responses of the mental health counsellors for the variable 'general interest'. For the third and fourth variables, 'required by organization to participate' and 'made changes in how you do your work or volunteer activities', the rehabilitation specialists and nurses responded in a signifi-cantly different manner (p_ = 0.0127 and p_ = 0.0022, respectively). No significant differences were noted for the variables 'chance to network with others', 'confirmed what you are already doing is O.K.', and 'increased substance abuse prevention activities' (Table 3). Overall, the four groups responded similarly to three variables and differently to four 51 variables. Despite the noted differences, the four groups were treated as one sample in order to increase the sample size and consequently maximize the statistical power. Table 3. Results of One-Way ANOVA - Independent/Dependent Variables by Health Care Professional Group Variable F Ratio df F Probability Independent Variables Need to do job 3.6756* or volunteer activities differently General interest 4.7800* Chance to network 1.3803 with others Confirm what you 0.9372 are already doing is O.K. Required by organization 4.9813* to participate Dependent Variables Increased substance 1.9930 abuse prevention activities Made changes in how 3.6751* you do your work or volunteer activities 3.253 3,264 3,257 3,256 3,256 3.254 3,268 0.0128 0.0029 0.2492 0.4232 0.0022 0.1155 0.0127 Note, df = degrees of freedom 52 Comparison of the Matched Samples to the Unmatched Samples Descriptive statistics, means (M) and standard deviations (SD), for the five demographic variables and the five selected situational variables, summarized the data used in comparing the matched respondents to the unmatched respondents. The descriptive statistics provide information about the distribution of the variables and allow for the identification of any outlying variables which could result in skewed results. A series of two-tailed t-tests of samples with independent means were done. The t-tests are used to determine if there is a statistically significant difference between the mean values of the selected variables for the study (matched) participants and the unmatched respondents. The series of t-tests was completed for the study sample as a whole and for each of the sub-groups of health care professionals (physicians, nurses, mental health counsellors, and rehabilitation specialists) individually. The analysis of the sub-groups was done in order to check if the individual sub-groups were adequately represented, as a combined group, by the study sample. Three statistical assumptions are made when calculating the t-test to determine differences between independent means: (a) the sample populations are normally distributed, (b) the variances of the two sample populations are equal, and (c) the two samples are independent. Despite these assumptions the t-test is "robust" with regards to violating the assumptions concerning the normal distribution and the homogeneity of variance (Hopkins, Glass & Hopkins, 1987). Thus, the use of this test was appropriate for the two independent samples used in this case even though the distributions are not normal. This statistical procedure was carried out for the total sample and for each health care professional sub-53 group. As such, the total sample was compared to each sub-group of health care professionals. Descriptive Statistics Descriptive statistics of demographics (age, gender, ethnicity, organization of employment and level of education attainment) were determined by calculating the frequencies, means and standard deviations for each health care professional group and for the combined group in order to summarize the characteristics of the sample population. Descriptive statistics were also used to indicate the distribution and to summarize the independent variable (reasons for participating in the CTS workshop) and the dependent variable (extent of application of learning) for the sample population. This was done by calculation of the frequency distributions, means (M), and standard deviations (SD) for the independent and dependent variables. The descriptive statistics also provide information about the distribution of the variables and allow for the identification of any outlying variables which could result in skewed results. Cross-Tabulations and Chi-Square Tests for Association To test the primary null hypothesis and the two subsidiary null hypotheses, a series of chi-square tests were done. Cross-tabulations of a 3 x 3 contingency table and a chi-square test was calculated for each of the five reasons for participation with each of the two measures of application of learning. This analysis was done for each of the four samples of health care professional groups and for the combined group in order to determine if any one group was influencing the study data. 54 A total of 50 chi-square tests were done to assess the extent of the possible relationship between reasons for participation and application of learning. Using two variables at a time (one reason for participation with one indicator of application of learning), the chi-square test compares the actual frequencies with the expected frequencies for all possible combinations of the categories of the two variables. The significance of p_ < .01 was used. It is the standard level of significance in social sciences research for a sample size of greater than 100 (Schumacher & McMillan, 1993). Each of the response scores for the variables (independent and dependent) was collapsed down to three categories from five. This allowed for an adequate number of responses in each of the 9 cells of the contingency tables. The responses to the reasons for participation variable are represented by low, medium and high scores. A low score is equal to responses 1 and 2 (1 being 'no influence'), a medium score is equal to response 3 and a high score is equal to responses 4 and 5 (5 being 'extremely influential'). The responses to the measures of application of learning are also represented by low, medium and high scores. A low score is equal to responses 1 and 2 (1 being equal to 'not at all'), a medium score is equal to response 3 and a high score is equal to responses 4 and 5 (5 being equal to 'substantial'). Rationale for the Chi-Square Tests The chi-square test is a non-parametric test which is appropriate for use with the data in this study. The data is measured at the ordinal level, is not normally distributed and the variances are not homogenous. These characteristics of the data violate the assumptions underlying the use of a parametric test therefore a non-parametric test must be used. The chi-55 square test is an appropriate test to help answer the research question under study - is there a relationship between reasons for participation and application of learning? One-Wav ANOVA Tests of Indicators of Application of Learning bv Situational and Demographic Characteristics A series of one-way ANOVA tests were carried out in order to answer the second general question; do demographic and situational factors help explain the relationship between reasons for participation and subsequent application of learning. The indicators of application of learning used were 'increased substance abuse prevention activities' and 'made changes in how you do your work and volunteer activities'. The post hoc statistical procedure, Tukey's 'honestly significant difference', was used subsequent to the ANOVA test. This procedure is used when a significant difference is noted between the group of means. Using this statistical test, the researcher is able to identify those means which are different from each other (Schumacher & McMillan, 1993). As previously noted, the selected variables have been identified as possible situational and demographic influences on application of learning. The demographic variables include age, gender, ethnicity, educational attainment, organization of employment. The selection process of the situational variables used for the comparison was informed by the literature (Baldwin, et. al, 1991; Cafferella, 1994; Kemerer, 1991; Parry, 1990), current under-standing of possible influences on application of learning, and the conceptual framework guiding the questionnaire design. Refer to page 62 for a listing of the situational variables. 56 Rationale for Using the One-Wav ANOVA Tests The ANOVA test is used instead of using multiple t-tests to compare all possible pairs of means generated for the indicators of application of learning. The ANOVA test uses the variances of the groups to calculate the degree of difference in the means. Thus, all the means are compared simultaneously, decreasing the likelihood of making a type I error (finding a significant difference by chance when none exists). Limitations of the Design The limitations of this study relate to the method of sample selection, the sample size and the data collection procedure. Thus, the generalizability of the results is a major limitation. The generalizability of the results of this study are limited to health care professionals with characteristics similar to those who participated in the study and to training situations similar to the CTS training workshops. Generalizations beyond these boundaries must be made with caution. Furthermore, the selection of the sample is biased due to its volunteer nature. As such, the characteristics of the volunteers may be different from those who chose not to participate resulting in non-response bias of the data. Determination of how the matched respondents differ from the total population may help to decrease the effect of this limitation if significant differences are not found. For this reason a comparison of selected variables related to application of learning was done between the matched respondents and those who did not result in matched responses at the follow-up stage. The small sample size (n=281), due to small percentage of matched responses of the health care professionals, is another limiting factor. Statistically significant results may not be 5 7 found when, in fact, they would exist with a larger sample size. (Schumacher & McMillan, 1993). Lastly, it is recognized that the self-reported data collected using the survey questionnaires is a limitation. All of the findings are subject to the respondents providing truthful and accurate reports of their reasons for participating in the CTS workshop and subsequent application of training at their work-place. Respondents may answer based upon what they think the researcher wants to hear and what they think is a socially acceptable response. Responses cannot be considered completely objective or valid. 5 8 Chapter Four Results The findings of the statistical analyses used to inform this investigation and address the research question guiding this study will be presented. This will be followed by a brief description of the demographic characteristics of the respondents. These data should assist the reader in the establishment of the external validity of this study. To further demonstrate generalizability, the responses of the matched (at pre, post, and follow-up) respondents and unmatched respondents were compared for selected situational variables from the Participant Profile and Feedback questionnaires. The situational variables represent factors to which the conceptual framework guiding the study may influ-ence application of learning. T-tests of the mean scores of the five selected variables will be presented to demonstrate if any differences exist between the two groups. To answer the research question guiding this study, mean responses for the five reasons for participation and the two indicators of application of learning will be presented. This is followed by a presentation of the results of the cross tabulations of reasons for participation by application of learning. The results of the cross-tabulations and chi-square test for the sub-group of nursing professionals will then be presented to help the reader better understand the findings. A more detailed description of the demographic characteristics of the total sample of respondents and the sub-group of nurses will then be presented. To further elaborate on the salient findings of this study, a series of one-way ANOVA tests will be presented. These tests were done to determine what influence, if any, the 59 demographic and situational variables had on the degree of the respondents' application of learning. Characteristics of the Respondents A matched response rate of 18.8% was achieved. Of the 1493 participants surveyed at the physicians, nurses, mental health counsellors, and rehabilitation specialists CTS training workshops, only 281 respondents met the criteria for inclusion in the study. All respondents answered the Participant Profile, Participant Feedback, and Follow-Up questionnaires and were matched anonymously or confidentially. These respondents will be referred to as the matched respondents. The number of respondents classified by health care professional group is presented in Table 4. In all, 58 respondents (20.9%) were male and 219 (79.1%) were female. The majority of respondents were between the age of 36 and 55 years; 173 respondents (62.7%) were represented by this age group. Of the total number of respondents, 213 (77.7%) were Caucasian. The next largest ethnic group was African Americans who were represented by 43 respondents (15.7%). A total of 230 respondents (83.6%) had achieved a college or graduate school degree. Of these 230 respondents, 132 respondents (48.0%) had earned a degree in graduate school. Although not representative of the majority, 37.6% (n = 103) of the respondents indicated that they were employed in a hospital setting. A further 18.3% (n = 50) and 16.4% (n = 45) were employed in government agencies or in educational settings, respectively. The average study participant is a health care professional, most likely a nurse, and is a Caucasian female. She is between the age of 36 and 55, is very well educated and works in a hospital setting. 60 Table 4. Respondents Classified bv Health Care Professional Group Profession Number Percent Physicians 36 12.8 Nurses 129 45.9 Mental Health Counsellors 82 29.1 Rehabilitation Specialists 34 12.1 TOTAL 281 100.0 Response Bias and External Validity The mean (M) responses and standard deviations (SD) of the matched respondents and unmatched respondents for the situational variables are presented in Table 5. These variables were used to assess the external validity and response bias of this investigation. Matched respondents were compared to the unmatched respondents. In the latter group are those participants who either did not respond to all of the questionnaires or did not provide codes that could be matched for all three questionnaires. The five situational variables used for the comparison have been identified in the literature as possible situational influences on application of learning. The situational variables are as follows: informed about the purpose of the workshop, previous training in substance abuse prevention, usefulness of the workshop, relevance of the CTS workshop to your job, and sufficient resources exist in your organization. 61 Table 5 Summary of Situational Characteristics of the Matched Sample and the Unmatched Sample Unmatched Sample Matched Sample M n SD M n SD Situational Characteristics Informed about 6.26 1108 2.70 6.34 275 2.81 purpose of workshop Previous training 2.90 1152 1.02 3.06 279 1.00 in substance abuse prevention Usefulness of 7.56 1060 2.01 7.73 280 1.98 this workshop Relevant to 3.80 1049 1.04 3.95 278 1.03 your job Sufficient 3.47 1025 1.01 3.30 274 1.03 resources exist in your organization Note, n = number of respondents; M = mean; SD = standard deviation. The responses of the matched sample (matched at pre, post, and follow-up) versus the unmatched sample for the five situational variables were not significantly different (see Table 6). 62 Table 6. Summary of 2-Tailed t-Tests of the Matched Sample and the Unmatched Sample t-Value df Probability Situational Characteristics Informed about -0.42 1381 0.677 purpose of workshop Previous training -2.45 1429 0.014 in substance abuse prevention Usefulness of -1.22 1338 0.222 this workshop Relevant to -2.14 1325 0.033 your job Sufficient resources 2.36 1297 0.018 exist in your organization Further t-tests were carried out for each health care professional sub-group of matched versus unmatched respondents. The same situational variables that are used for the combined group of health care professionals were also used for each sub-group analyses. These additional tests allow one to determine if differences were also not apparent for each sub-group of health care professionals. The results are summarized in Table 7. Both the matched (at pre, post, and follow-up) physician and rehabilitation specialist groups did not differ in their responses, when compared to the unmatched physician and rehabilitation specialist groups, on any of situational variables analyzed. 63 Table 7. Summary of Differences Between the Matched Sample and Unmatched Sample for the Combined Sample and Each Health Care Professional Sub-Group Mental Rehabil-Health itation Combined Physicians Nurses Counsellors Specialists Sample Situational Characteristics Informed about purpose of workshop (E NS = .806) (E NS = .672) (E: S =.009) (E NS = .766) (E NS = .677) Previous training in substance abuse prevention (E NS = .606) (E NS = .038) (E: NS =.132) NS =.673) (E NS = .014) Usefulness of this workshop (E= NS =.663) (E NS = .024) (E= NS =.711) (E= NS =.328) (E= NS =.222) Relevant to your job (E NS =.623) (E S =.005) (E: NS = .540) (E NS =.623) (E NS =.033) Sufficient resources exist in your organization (E NS = .232) (E NS =.455) (E: NS =.334) (E NS = .189) (E NS = .018) Note. S = p. < .01 and NS = p_ > .01 The nursing respondents who matched at pre, post, and follow-up had similar responses to the unmatched nursing respondents on all of the variables except for the variable representing job relevancy. On a scale of 1 (not at all) to 5 (completely), the matched nurses reported their experience at the CTS workshop as being significantly more relevant to their jobs (M = 4.04, SD = 0.99) than the unmatched nursing respondents (M = 3.75, SD = 1.06), t(694) = 2.85, p. = .005. 64 The matched group (at pre, post, and follow-up) of mental health counsellors differed from the unmatched group of mental health counsellors on their responses to the variable, 'informed about the purpose of the workshop'. This variable was rated on a scale of 1 = not at all to 10 = completely. The mean response of the matched group of mental health counsellors (M = 7.09, SD = 2.51) was significantly greater than the mean response of the unmatched group of mental health counsellors (M = 6.24, SD = 2.6), t(409) = 2.63, 2 = .009. The matched sample of mental health counsellors were more informed about the purpose of the workshop prior to participating than were the unmatched sample of mental health counsellors. The above results are similar for each of the health care professional sub-groups and the combined sample. Despite no consistent differences noted for all four sub-groups and the combined sample, a response bias in the study sample is still acknowledged. The respondents used as the study sample answered all three questionnaires and their responses were matched anonymously or confidentially by participant codes. This fact alone, indicates a difference from the unmatched respondents who did not provide matched data for all three question-naires. Therefore, the response bias evidenced by the above results must be taken into account when interpreting the results used to test the hypothesis of this study. Summary of Reasons for Participation The mean (M) responses and standard deviations (SD) of the matched group of respondents for their reasons for participating in the CTS workshops are presented in Table 8. On the Participant Profile Questionnaire, the respondents were asked to rate each reason for participation on a 5-point scale, where 1 = no influence and 5 = extremely influential. The reason for participation, 'required by organization to participate', was rated with the 65 lowest mean score (M = 1.96, SD = 1.37). This indicates participation in the CTS workshop was weakly influenced by external requirements. 'Required by organization to participate' was not a strong influence for respondents in choosing to participate in the CTS training workshops. In addition to having the lowest mean score, the responses to this reason for participation had the most variability. 'General interest' was rated with the highest mean score by the respondents and had the least variability (M = 4.16, SD = 0.86). Thus, having a general interest in the topic area of the workshop was an influential reason for participation by most participants. The remairiing three reasons for participation - 'need to do your job or volunteer activities differently', 'confirm what you are already doing is O.K.' and 'chance to network with others' were all rated similarly as shown by their mean scores in Table 8. These three reasons for participation were all somewhat influential in terms of influencing CTS participation. Frequency distributions for each of the reasons for participation are in Appendix D. An examination of the frequency distributions reveals that the data are not normally distributed. For the variable, 'general interest', the responses cluster in the ratings of 3, 4 and 5 on the 5-point scale. The largest percent (41.4%) of respondents is represented by a rating of 5 (extremely influential). The data for this variable is negatively skewed. At the other extreme is the variable 'required by organization to participate'. The responses to this variable are positively skewed. The largest percent of respondents (59.6%) rated this variable with 1 (no influence). The remaining three variables demonstrate a cluster in the ratings of 3 and 4 on the 5-point scale. The skewed data leads to decreased numbers of respondents at the extremes of the variable ratings. This has lead to decreased statistical validity of some of the further data analyses using the chi-square tests. 66 Table 8. Summary of Reasons for Participation Reason for Participation M n SD Need to do job or volunteer activities differently 3.55 257 1.16 Confirmed what you are already doing is O.K. 3.03 260 1.28 Chance to network with others 3.66 261 1.24 General interest 4.16 268 0.84 Required by organization to participate 1.96 260 1.37 Note, n = number of respondents; M = mean; SD = standard deviation; range of possible scores = l(no influence) to 5(extremely influential). Summary of Indicators of Application of Learning Table 9 presents mean responses of the matched group of respondents for the extent of application of learning resulting from participation in the CTS workshops. On the Follow-Up questionnaire, the respondents were asked to rate the two variables that indicated application of learning. The two variables were: 'increased substance abuse prevention activities' and 'made changes in how you do your work or volunteer activities'. Both were rated on a 5-point scale, where 1 = not at all and 5 = substantial. The mean scores for the two indicators of application of learning were rated similarly (see Table 9). The two indica-tors of application of learning were reported in the mid-range, between 'no' application of 67 Table 9. Summary of Indicators of Application of Learning Indicator of Application of Learning M n SD Increased substance 3.01 258 1.28 prevention activities Made changes in how you 3.02 272 1.16 you do your work or volunteer activities Note, n = number of respondents; M = mean SD = standard deviation; range of possible scores = l(not at all) to 5(substantial). learning to 'substantial' application of learning, indicating that some application of learning did take place. Frequency distributions for the two indicators of application of learning are in Appendix D. The participants' responses for the extent of application of learning resulting from the workshop were clustered at the 3 and 4 ratings on the 5-point. These data also were not normally distributed, in both cases the data leans towards a negative skew. Cross Tabulations and Chi-Square Tests of Association Cross tabulations of 3 x 3 contingency tables were done for each of the five reasons for participation and the two indicators of application of learning. Each 5-point variable rating was collapsed to three categories; low, middle, and high. Thus, each contingency table had nine cells. A total of 10 cross-tabulation procedures were carried out. These procedures 68 were done in order to test the null hypothesis of this study - there is no significant relationship between reasons for participation and subsequent application of learning. Voluntary Reasons for Participation The cross tabulations and subsequent chi-square tests revealed significant relationships for three of the four voluntary reasons for participation ('need to do job or volunteer activ-ities differently', 'confirm what you are already doing is O.K.', and 'chance to network with others') and the indicators of application of learning. The first voluntary reason for participation, 'need to do job or volunteer activities differently' was significantly associated with the two indicators of application of learning -'made changes in how you do your work or volunteer activities' (X2[4, N = 251] = 24.67, p_ = .000) and 'increased substance abuse prevention activities' Q?[4, N = 237] = 24.24, p_ = .000). Those respondents who were influenced to participate because they wanted to do something differently in their job or volunteer activities also indicated that they had experienced a substantial degree of application following CTS training. Alternatively, respon-dents who rated 'need to do job or volunteer activities differently' as a low influence for participating in the CTS workshop also rated the indicators of subsequent application of learning at the workplace as low (see Tables 10 and 11). The second voluntary reason for participation, 'confirm what you are already doing is O.K.', was also significantly associated with application of learning (see Table 12 and 13). As this reason for participation became more influential (from somewhat influential to extremely influential), the degree of application of learning increased, from 'not at all' to 'substantial'. Alternatively, as the influence of this reason for participation decreased 69 Table 10. 'Made changes in how vou do your work or volunteer activities' bv 'Need to do job or volunteer activities differently' Need to do job or volunteer activities differently LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 55.8 33.8 22.9 in how you do your work or MID 32.6 35.3 29.3 volunteer activities HIGH 11.6 30.9 47.9 TOTAL n=43 n=68 n=140 X2 = 24.67, E = .000 Table 11. 'Increased substance abuse prevention activities' bv 'Need to do job or volunteer activities differently' Need to do job or volunteer activities differently LOW(%) MIDDLE(%) HIGH(%) Increased LOW 66.7 31.3 27.6 substance abuse MID 17.9 31.3 23.1 prevention activities HIGH 15.4 37.5 49.3 TOTAL n=39 n=64 n=134 X2 = 24.24, p. = 0.000 70 Table 12. 'Increased substance abuse prevention activities' by 'Confirm what you are already doing is O.K.' Confirm what you are already doing is O.K. LOW(%) MIDDLE(%) HIGH(%) Increased LOW 51.3 34.3 21.9 substance abuse MID 21.1 23.9 27.1 prevention activities HIGH 27.6 41.8 51.0 TOTAL n=76 n=67 n=96 ^ = 16.92, p_ = .002 Table 13. 'Made changes in how you do your work or volunteer activities' by 'Confirm what you are already doing is O.K.' Confirm what you are already doing is O.K. LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 43.2 31.0 19.6 in how you do your MID 30.9 36.6 28.4 work or volunteer HIGH 25.9 32.4 52.0 activities TOTAL n=81 n=71 n=102 ^ = 18.09, p. = .001 71 (towards somewhat influential), the degree of the application of learning also decreased. As such, a significant association was seen between 'confirm what you are already doing is O.K.' and the two indicators of application of learning - 'made changes in how you do your work or volunteer activities' ^(4, N = 254) = 18.10,p_=.001, and 'increased substance abuse prevention activities', Z2(4, N = 239) = 16.92, p_ = .002. The third voluntary reason for participation, 'chance to network with others', was also found to be significantly associated with the two indicators of application of learning (see Tables 14 and 15). The greater the influence the reason of 'chance to network with others' had on participation, the more substantial the application of learning as indicated by the variables - 'made changes in how you do your work or volunteer activities', ^(4, N = 254) = 13.65, p_ = .008 and 'increased substance abuse prevention activities', X2(4, N = 240) = 23.39, p_ = .000. Table 14. 'Made changes in how you do your work or volunteer activities' bv 'Chance to network with others' Chance to network with others LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 50.0 34.0 22.8 in how you do your work or MID 23.9 34.0 34.2 volunteer activities HIGH 26.1 32.0 43.0 TOTAL n=46 n=50 n=158 X2 = 13.65, p_ = .008 72 Table 15. 'Increased substance abuse prevention activities' by 'Chance to network with others' Chance to network with others LOW(%) MIDDLE(%) HIGH(%) Increased LOW 59.1 37.0 25.3 substance abuse MID 27.3 26.1 24.0 prevention activities HIGH 13.6 37.0 50.7 TOTAL n=44 n=46 n=150 X2 = 23.40, p = -000 The association of the fourth voluntary reason for participation, 'general interest' with the indicators of application of learning was not statistically significant (see Tables 16 and 17). The non-significant associations found, for this reason for participation and the indicators Table 16. 'Made changes in how you do your Work or volunteer activities' by 'General interest' General interest LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 20.0 50.0 26.7 in how you do your work or MID 40.0 25.0 33.0 volunteer activities HIGH 40.0 25.0 40.3 TOTAL n=10 n=44 n=206 Xj = 10.05, p = .039 73 of application of learning must be interpreted with caution. A chi-square test is unreliable with an expected cell frequency of less than 5. In both cases, three of the nine cells of the cross-tabulations had a frequency of less than 5. The three cells that had an expected cell fre-quency of less than 5 fell under the heading of a 'low' rating for the influence of 'general interest' on deciding to participate. Very few respondents (n = 10) reported a low rating for the influence of this reason for participation, while a large number (n = 206) of respondents indicated that 'general interest' was an influential factor in their decision to participate in the CTS workshop. Because of the skewed frequency distribution for the influence of this reason for participation and the subsequent low cell frequency in three of the cells of the contingency table, the results may be indicating a non-significant association when there is one. Table 17. 'Increased substance abuse prevention activities' by 'General interest' LOW(%) General interest MIDDLE(%) HIGH(%) Increased LOW 40.0 52.5 30.3 substance abuse MID 20.0 25.6 25.6 prevention activities HIGH 40.0 30.0 44.1 TOTAL n=10 n=40 n=195 ¥ = 7.47, p = .113 74 Non-Voluntary Reasons for Participation The cross-tabulations and chi-square tests revealed that the non-voluntary reason for participation 'required by organization to participate' was not significantly related to the two indicators of application of learning (see Tables 18 and 19). Those respondents who were influenced to participate in the CTS workshop because they were required to do so by their employer, did not show any difference in degree of application of learning as compared to those respondents who were not influenced by this reason for participation. Table 18. 'Made changes in how you do your work or volunteer activities' by 'Required by organization to participate' Required by organization to participate LOW(%) MIDDLE(%) HIGH(%) 27.1 3L0 43.2 33.7 24.1 27.3 39.2 44.8 29.5 TOTAL n=181 n=29 n=44 Made changes LOW in how you do your work or MID volunteer activities HIGH Xr = 5.31, p_ = .257 75 Table 19. 'Increased substance abuse prevention activities' by 'Required by organization to participate' Required by organization to participate LOW(%) MIDDLE(%) HIGH(%) Increased LOW 31.8 27.6 47.5 substance abuse MID 24.7 27.6 25.0 prevention activities HIGH 43.5 44.8 27.5 TOTAL n=170 n=29 n=40 X2 = 4.98, p_ = .289 Summary of Significant Relationships Between Reasons for Participation and Application of Learning Tables 20 and 21 present a summary of the associations between the reasons for participation and the indicators of application of learning. The results for the chi-square tests of the total sample were compared to the results obtained by examining each sub-group of health care professional separately. This was done in order to see if any of the sub-groups differed from the overall group. The four groups were previously compared (see Table 3) ti determine if they differed significantly on their responses to the independent and dependent variables. Differences were noted on four of the variables, therefore some differences in significant relationships were anticipated. The results for the sample of nurses closely resemble the total sample in terms of significant associations between the two variables. When examined individually, the results of the chi-square tests for the samples of physicians, mental health counsellors and rehabilitation 76 Table 20. Summary of Associations Between the Reasons for Participation and 'Made changes in you do you work or volunteer activities' for the Combined Sample and Each Health Care Professional Sub-Group Reason for Participation Combined Sample Physicians Nurses Mental Health Counsel-lors Rehabil-itation Special-lists Need to job or volunteer activities differently S (p = .000) NS (E=.080) S* (E=.000) NS* (E=.520) NS* (E=.273) Confirm what you are already doing is O.K. S (E=.001) NS* (E=.166) S (E=.023) NS* (E=.160) NS* (E=.935) Chance to network with others S (p=.008) NS* (E=.914) NS* (E=.127) NS* (E=.174) NS* (E=.346) General interest NS* (p_=.039) S* (E=.049) NS* (E=.359) NS* (E=.466) NS* (E=.540) Required by organization NS (E=.257) NS* (E=.441) NS (E=.986) NS* (E=.778) NS* (E=.530) to participate Note. S = E < 01 and NS = E > -01 f° r the combined sample; S = E < 05 and NS = E > .05 for the health care professional sub-groups; * indicates chi-square tests with cells with expected frequency of less than 5. 77 Table 21. Summary of Associations Between the Reasons for Participation and 'Increased substance abuse prevention activities' for the Combined Sample and Each Health Care Professional Sub-Group Reason for Participation Combined Sample Physicians Nurses Mental Health Counsel-lors Rehabili-tation Special-ists Need to job or volunteer activities differently S (p. = .000) S* (E=.024) S* (E=.008) S* (p=.050) NS* (E=.782) Confirm what you are already doing is O.K. S (E=.002) NS* (E=.291) S (E=.007) NS* (E=.373) NS* (E = -478) Chance to network with others S (E=.000) NS* (E=.134) S* (E=.000) NS* (E=.206) NS* (E=.337) General interest NS* (E=.H3) NS* (E=.053) NS (£=•297) NS* (E=.644) NS* (E=.381) Required by organization NS (E=-289) NS* (E=.343) NS* (E=.911) NS* (E=.452) NS* (E=.459) to participate Note. S = E < 01 and NS = E > 01 for the combined sample; S = E < 05 and NS = E > -05 for the health care professional sub-groups; * indicates chi-square tests with cells with expected frequency of less than 5. specialists were not statistically significant. It is noted that the reliability of the significance of the chi-square test for the physicians, mental health counsellors and rehabilitation counsellors is questionable due to the large number of cells in the contingency tables with a 78 frequency of less than five. In all instances, three of the nine cells had a frequency of less than five. The low cell frequencies are due to the small sample sizes of the health care professional sub-groups; n = 36 for the physicians, n = 34 for the rehabilitation specialists, and n = 82 for the mental health counsellors. The results of the cross tabulations and chi-square tests for the sample of nurses were examined more closely because they appeared to be the one sub-group of health care profes-sionals influencing the overall data. The results of the cross tabulations and chi-square test will be presented. This will be followed by an examination of the demographic and situational variables in relation to the indicators of application of learning. Cross Tabulations and Chi-Square Tests of Association for the Sample of Nurses As was seen in the results of the cross tabulations and chi-square test for the sample population of this study, the data analyses for the sample of nurses also revealed significant associations for three of the four voluntary reasons for participation. Voluntary Reasons for Participation As was seen with the overall sample, three of the four voluntary reasons for participation were significantly associated with the indicators of application of learning. The first voluntary reason for participation, 'need to do job or volunteer activities differently' was significantly associated with both indicators of application of learning (see Table 22). When 'need to do job or volunteer activities differently' was a strong influence for participation, a substantial degree of 'increased substance abuse prevention activities' was reported, ^(4, N = 110) = 13.75, p_= .008. Conversely, when 'need to do job or volunteer activities differently' was not an influence for participation, 'increased substance abuse prevention 79 Table 22. Nurses' Ratings of 'Increased substance abuse prevention activities' bv 'Need to do job or volunteer activities differently' Need to do job or volunteer activities differently LOW(%) MIDDLE(%) HIGH(%) Increased LOW 65.0 33.3 25.4 substance abuse MID 20.0 33.3 22.2 prevention activities HIGH 15.0 33.3 52.4 TOTAL n=20 n=27 n=63 X2 = 13.75, p = .008 activities' were rated as low. A similar significant relationship was seen between 'need to do job or volunteer activities differently' and the indicator of application of learning, 'made changes in how you do your work or volunteer activities', X2(4, N = 116) = 24.03, E = .000 (see Table 23). The second voluntary reason for participation, 'confirm what you are already doing is O.K.' was significantly associated with one of the indicators of application of learning, 'increased substance abuse prevention activities'QC2(4, N = 111) = 14.17, E = -007). As demonstrated in Table 24, substantial 'increased substance abuse prevention activities' were cited by nurses who attended the CTS workshop because they wanted to 'confirm what they were already doing is O.K.'. Alternatively, as the influence of this reason for participation (confirm what you are already doing is O.K.) decreased, the extent of application of learning (increased substance abuse prevention activities) also decreased. 80 A significant relationship was not demonstrated by the chi-square test for this voluntary reason for participation and 'made changes in how you do your work or volunteer activities' as an indicator of application of learning (see Table 25). Table 23. Nurses Ratings of 'Made Changes in how you do your work or volunteer activities' by 'Need to do job or volunteer activities differently' Need to do job or volunteer activities differently LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 54.5 26.9 11.8 in how you do your work MID 40.9 38.5 33.8 or volunteer activities HIGH 4.5 34.6 54.4 TOTAL n=22 n=26 n=68 X2 = 24.03, p_ = .000 Table 24. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'Confirm what you are already doing is O.K.' Confirm what you are already doing is O.K. LOW(%) MIDDLE(%) HIGH(%) Increased LOW 58.1 30.0 20.0 substance abuse MID 22.6 23.3 26.0 prevention activities HIGH 19.4 46.7 54.0 TOTAL n=31 n=30 n=50 X2 = 14.17, p. = .007 81 Table 25. Nurses' Rating of 'Made changes in how you do your work or volunteer activities' by 'Confirm what vou are already doing is O.K.' Confirm what you are already doing is O.K. LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 37.5 12.9 18.5 in how you do your work or MID 37.5 48.4 27.8 volunteer activities HIGH 25.0 38.7 53.7 TOTAL n=31 n=31 n=54 2? = 11.32, n = .023 The third voluntary reason for participation, 'chance to network with others', was also found to be significantly associated with one of the two indicators of application of learning. As the influence of the reason for participation, 'chance to network with others' increased, the indicator of application of learning, 'increased substance abuse prevention activities', was rated as being more substantial (see Table 26). As seen in Table 27, the association between 'chance to network with others' and the second indicator of application of learning, 'made changes in how you do your work or volunteer activities' was not significant. 82 Table 26. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'Chance to network with others' Chance to network with others LOW(%) MIDDLE(%) HIGH(%) LOW 70.6 36.4 23.0 MID 29.4 27.3 24.3 HIGH 0.0 36.4 52.7 TOTAL n=17 n=22 n=74 X2 = 19.26, p_ = .000 Table 27. Nurses' Ratings of 'Made changes in how you do your work or volunteer activities' by 'Chance to network with others' Chance to network with others LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 41.2 21.7 19.0 in how you do your work or MID 41.2 43.5 32.9 volunteer activities HIGH 17.6 34.8 48.10 TOTAL n=17 n=23 n=79 vz = 7.17, E = .127 Increased substance abuse prevention activities The fourth voluntary reason for participation, 'general interest', was not significantly associated with either of the two indicators of application of learning (see Tables 28 and 29). 83 The significance of this result must be interpreted with caution. As previously noted, a chi-square test is unreliable with an expected cell frequency of less than 5. For both indicators of application of learning, 'increased substance abuse prevention activities' and 'made changes in how you do your work or volunteer activities', four of the nine cells of the cross-tabulations had a frequency of less than 5. The three of the four cells that had an expected cell frequency of less than 5 fell under the 'low' rating for the influence of 'general interest' on deciding to participate. Very few nurses (n = 5) reported a low rating for the influence of this reason for participation, while a large number (n = 91) of nurses indicated that 'general interest' was a strong influential factor in their decision to participate in the CTS workshop. The skewed frequency distribution for the rating of the influence of this reason for participation, and the low cell frequency in four of the cells of the contingency table, may have resulted in a non-significant association when it was actually significant. Table 28. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'General interest' General interest LOW(%) MIDDLE(%) HIGH(%) Increased LOW 60.0 50.0 28.6 substance abuse MID 20.0 16.7 26.4 prevention activities HIGH 20.0 33.3 45.1 TOTAL n=5 n=18 n=91 ¥ = 4.90, n = -297 84 Table 29. Nurses' Ratings of 'Made changes in how you do your work or volunteer activities' by 'General interest' General interest LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 4O0 3S\9 19.6 in how you do your work MID 40.0 27.8 37.1 or volunteer activities HIGH 20.0 33.3 43.3 TOTAL n=5 n=18 n=97 2? = 4.36, D = .359 Non-Voluntary Reasons for Participation The non-voluntary reason for participation, 'required by your organization to participate (in the CTS workshop)' was not related to either of the indicators of application of learning (see Tables 30 and 31). The reports of the extent of the indicators of application of learning did not differ with the ratings of the influence of 'required by organization to participate' on participation. In this case, the chi-square test is an unreliable test for significance because four of the nine cells for each of the contingency tables had a frequency of less than five. The low cell frequencies were due to the small number of nurses who were influenced to participate because they were required to do so. For the cross-tabulation with the variable 'increased substance abuse prevention activities', 12 nurses were 'highly' influenced to participate and 12 nurses indicated that they were somewhat influenced ('middle' rating) to participate because they were required to do so. The number of nurses were similar for the variable -85 'made changes in how you do your job or volunteer activities'; 12 nurses were somewhat influenced ('middle' rating) and 14 nurses were highly influenced to participate because of a requirement to participate. Table 30. Nurses' Ratings of 'Increased substance abuse prevention activities' by 'Required by organization to participate' Required by organization to participate LOW(%) MIDDLE(%) HIGH(%) Increased LOW 33.0 25.0 33.3 substance abuse MID 23.9 25.0 33.3 prevention activities HIGH 43.2 50.0 33.3 TOTAL n=88 n=12 n=12 2? - 0.99, p_ = .911 Table 31. Nurses Ratings of 'Made changes in how vou your work or volunteer activities' by 'Required by organization to participate' Required by organization to participate LOW(%) MIDDLE(%) HIGH(%) Made changes LOW 21.7 16.7 21.4 in how you do your work or MID 37.0 33.3 35.7 volunteer activities HIGH 41.3 50.0 42.9 TOTAL n=92 n=12 n=14 X2 = 5.31, p_ = 0.256 86 In order to better understand the relationship between the reasons for participation and application of learning, the sample of nurses were examined more closely. The demographic characteristics of this sample will be summarized. Following this summary, the findings of a series of one-way ANOVA tests of the demographic characteristics and situational variables and application of learning will be presented. Summary of Demographic Characteristics The sample of nursing professionals who met the criteria for inclusion in this study was comprised of 129 nurses. The nurses made up 45.9% of the total sample of health care professionals (see Table 4). Of the 129 nurses, 122 (97.6%) were female. This is slightly higher than the percentage of females representing the total sample of respondents (see Table 32). Males were representative of 2.4% (n = 3) of the sample of nurses while they were representative of 20.9% (n = 58) of the total sample of matched health care professional respondents. Table 32. Distribution of Respondents bv Gender Nurses Combined Sample Gender Number Percent Number Percent female 122 97.6 219 79.0 male 3 2.4 58 20.9 TOTAL 125 100.0 277 100.0 87 Age of Respondents The majority of the nursing respondents (64.8%) were between the ages of 36 and 55 years. A presentation of the distribution of nursing respondents and the total sample of respondents by age can be found in Table 33. Table 33. Distribution of Respondents bv Age Nurses Combined Sample Age Number Percent Number Percent < 25 1 0.8 10 3.6 26-35 19 15.2 48 17.4 36-45 48 38.4 105 38.0 46-55 33 26.4 68 24.6 > 55 24 19.2 45 16.3 TOTAL 125 100.0 276 100.0 Ethnicity Caucasians made up the greatest number of respondents (n = 213; 77.7%) in the combined sample. Of these 213, 99 were nurses. Refer to Table 34 for a comprehensive distribution of nursing respondents and the total sample of respondents by ethnicity. There is a slightly higher percentage of Caucasians in the nursing sample, than in the combined health care professional sample. 88 Table 34. Distribution of Respondents by Ethnicity Nurses Combined Sample Race Number Percent Number Percent African American 17 13.6 44 16.1 Caucasian 99 79.2 213 77.7 Hispanic 6 4.8 8 2.9 American Indian - 0.0 1 0.4 Asian American 2 1.6 1 0.4 Other 4 3.2 7 2.6 West Indian (1) (1) Jamaican - (1) Asian Australian - (1) Hungarian - (1) no information (3) (3) TOTAL 125 100.0 274 100.0 Level of Educational Attainment In the combined sample, 132 respondents (48.0%) indicated that they had completed a graduate degree and 98 respondents (35.6%) completed a college degree. Of these 230 well-educated respondents, 34 nurses had completed a graduate degree and 58 had completed a college degree. The distribution of respondents' level of educational attainment is presented in Table 35. It is noted that two respondents cited less than college level education. It is suspect that someone employed as a nurse would have such a minimal level of formal 89 education. Perhaps the question was misinterpreted, answered inaccurately, or the respondents may be nursing assistants. Table 35. Distribution of Respondents by Level of Educational Attainment Nurses Combined Sample Education Number Percent Number Percent Grade School 1 0^ 8 1 0.4 or some High School High School 1 0.8 5 1.8 Some College or Vocation- 30 24.2 39 14.2 al School College 58 46.8 98 35.6 Degree Graduate 34 27.4 132 48.0 Degree TOTAL 124 100.0 275 100.0 Organization of Employment All subjects are health care professionals who are currently employed or working for volunteer organizations. A variety of organizational settings are represented by the study sample (see Table 36). Most of the combined sample of health care professionals (n = 198) are employed in government agencies, hospitals and educational settings. The greatest single organization of employment is hospitals (n = 103; 37.7%). This holds true for both the 90 combined sample of health care professionals and the nursing sample. Of the total number of health care professionals employed in hospitals, the majority are nurses (n = 63; 61.2%). Table 36. Distribution of Respondents by Organization of Employment Nurses Combined Sample Organization Type Number Percent Number Percent Government 16 12.9 50 18.3 Law - Legal 0 0.0 5 1.8 Hospital 63 50.8 103 37.7 Private Practice 1 0.8 8 2.9 Education 28 22.6 47 17.2 Religious Organization - 0.0 1 0.4 Volunteer Organization 2 1.6 9 3.3 Business - 0.0 2 0.7 Not representing an organization 4 0.8 20 7.3 TOTAL 124 100.0 273 100.0 In summary, the average respondent in this study is a Caucasian, female between the age of 36 and 55 years, has a college degree, possibly a graduate degree, and is employed in a hospital setting. The average nursing professional who participated in this study has similar 91 characteristics as compared to the average study respondent; she is Caucasian, between the age of 36 and 55 years, has a college degree and is employed in a hospital setting. Variables Influencing Application of Learning A series of one-way analysis of variance (ANOVA) tests was completed for the sample of nurses to determine if differences in application of learning were apparent for individuals who have different demographic and situational characteristics. The five situational variables were identified in the literature as possible influences for application of learning. Tables 37 and 38 present a summary of the results of the one-way ANOVA tests. Significant differences were noted for the nurses' ratings of the indicators of application of learning by their responses to four of the five situational variables. A 5-point rating scale was used for the first variable, 'previous training in substance abuse prevention activities' The scale was follows: 1 = not at all, 2 = very little, 3 = some, 4 = a lot, and 5 = extensive. Nurses who indicated that they had 'very little' to 'a lot' of previous training in substance abuse prevention (i.e., rated this variable with '2', '3', and '4'), rated 'increased substance abuse prevention activities' significantly greater (M = 2.96, M = 3.09, and M = 3.36 respectively) than those nurses who indicated 1 = not at all or 5 = extensive for their previous training in substance abuse prevention (M = 1.56 and M = 3.00 respectively). Similar differences were noted between this variable, 'previous training in substance abuse prevention', and the ratings of 'made changes in how you do your work or volunteer activities'. Nurses who indicated that they had 'very little' to 'a lot' of previous training in substance abuse prevention (i.e., rated this variable with '2', '3', and '4'), rated the variable 'made changes in how you do your work or volunteer activities' as significantly more substantial (M = 3.17, M = 3.43, and M = 3.24 re-92 spectively) than did those nurses who indicated 1 = not at all or 5 = extensive for their previous training in substance abuse prevention (M = 1.89 and M = 2.67 respectively). The second variable, 'relevant to your job' also led to differences in the extent that application of learning was reported by the group of nurses. This variable was rated on a scale of 1 = not at all to 5 = completely. Nurses who described their experiences in the CTS workshop as being 'completely' relevant to their jobs, reported moderate degrees of application of learning (M = 3.69) for the indicator 'made changes in the way you do your work or volunteer activities'. The extent of application of learning reported by this group was significantly greater as compared to the nurses who described the relevance of the CTS workshop with a rating of '1', '2', '3', or '4' QA = 2.00, M = 2.00, M = 2.55, and M — 2.774 respectively). A similar difference was noted for the second indicator of application of learning, 'increased substance abuse prevention activities'. Nurses who described their experiences in the CTS workshop as being 'completely relevant to their jobs, reported moderate degrees of application of learning (M = 3.68). This degree of application of learning was significantly greater than the degrees of application of learning reported by the groups of nurses who described the relevance of the CTS workshop with a rating of '1', '2', and '3' (M = 2.00, M = 2.00, and M = 2.69 respectively). The third variable that resulted in a significant difference of application of learning was 'usefulness of the workshop'. This variable was rated on a 10-point scale: 1 = not at all to 10 = completely. The extent of application of learning as indicated by 'increased substance abuse prevention activities' and 'made changes in how you do your work or volunteer activities' differed depending upon the usefulness of the workshop. 93 The group of nurses who rated the usefulness of the workshop as 'completely' useful (i.e., a rating of '10'), indicated a higher degree of 'increased substance abuse prevention activities' (M = 3.34) compared to nursing individuals who rated the workshop as moderately useful (i.e., a rating of '5'). A mean value of 1.25 for the extent of application of learning was reported by the nursing individuals who rated the workshop as moderately useful. A similar pattern was seen with the second indicator of application of learning, 'made changes in how you do work or volunteer activities'. Those nurses who rated the usefulness of the workshop as 'completely' useful, indicated a higher degree of application of learning (M = 3.61) when compared to the nurses who rated the workshop as not very useful to moderately useful (i.e., ratings of '2', '4', '5', '6', and '7'). The mean ratings of application of learning were 2.00, 2.00, 2.40, 2.63, and 2.64 respectively. Nurses who rated the usefulness of the workshop with a '8' or '9' also differed significantly in their rating of application of learning (M = 3.32, 3.43 respectively) compared to those nurses who rated the usefulness of the workshop as not very useful (i.e., ratings of '2' and '4'). The last variable resulting in significant differences for the means of application of learning is that of the availability of 'sufficient resources' at the workplace. A scale of 1 = not at all to 5 = substantial was used by the respondents to rate this variable. Nursing professionals who indicated a rating of '5' (substantial) for the existence of sufficient resources at their workplace, reported a significantly greater degree of the variable 'made changes in how you do your work or volunteer activities' (M = 3.70) than did those individuals who rated the variable of 'sufficient resources' with a '2' (M = 2.66). A significant difference was also noted between the means of the second indicator of application of learning, 'increased substance abuse prevention activities' (see Tables 38). 94 Nursing professionals who rated 'sufficient resources' with '5' and '4', respectively, reported mean values of 3.57 and 3.49 for 'increased substance abuse prevention activities'. These values of application of learning were significantly different from the mean value of 2.67 reported by the nurses who rated 'sufficient resources' with '2'. Table 37. Summary of One-Way ANOVAs for 'Made changes in how you do your work or volunteer activities' by Demographic and Situational Characteristics Demographic and Situational Characteristics df F Ratio F Probability Demographic Characteristics Age 4,116 1.27 .2843 Gender 1,119 0.53 .4665 Level of educational attainment 4,115 1.60 .1796 Etlinicity 4,116 1.92 .1123 Organization of employment 6,113 1.87 .0915 Situational Characteristics Previous training in substance abuse prevention 4,120 4.29 .0028* Usefulness of the workshop 8,115 2.96 .0048* Informed about the purpose of the workshop 4,44 0.22 .9277 Relevant to your job 4,119 6.30 .0001* Sufficient resources exist in your organization 4,114 3.47 .0103* Note, df = degrees of freedom. 95 Table 38. Summary of One-Way ANOVAs for 'Increased substance abuse prevention activities' bv Demographic and Situational Characteristics Demographic and Situational Characteristics df F Ratio F Probability Demographic Characteristics Age 4,110 Gender 1,113 Level of educational 4,109 attainment Ethnicity 4,110 Organization of 6,107 employment Situational Characteristics Previous training in 4,114 substance abuse prevention activities Usefulness of the 8,110 workshop Informed about the 4,42 purpose of the workshop Relevant to your j ob 4,113 Sufficient resources 4,108 exist in your organization 1.24 0.001 1.02 0.91 2.29 3.66 2.50 0.84 8.35 4.40 .2978 .9697 .4019 .4633 .0405 .0077* .0155* .5100 .0000* .0025* Note, df = degrees of freedom. 96 Chapter Five Discussion and Limitations This chapter provides a discussion of the major findings and limitations of this investigation. The main purpose of this study was to explore the linkage between antecedents to educational participation and subsequent outcomes. This was done through the investigation of a relationship between reasons for participation in CPE and application of learning. The main research question guiding this investigation was as follows: do health care professionals' reasons for participation in CPE have an impact on subsequent application of learning? The discussion begins by looking at the representation of the sample population. The findings associated with the response bias of the sample will also be discussed at this time. The salient findings that help to answer the research questions will then be discussed. Following this, the demographic and situational findings will be discussed in relation to application of learning. Finally, the limitations of the results will be addressed. Response Bias and Representation of the Study Sample Investigations into the representation of the sample population were done by addressing the issue of response bias. Although no significant differences were noted for the combined sample between the matched and unmatched groups, differences were noted between for the sub-groups of nurses and mental health counsellors. Therefore it is recognized that a response bias does exist. In addition, the matched respondents differ from the unmatched respondents because they responded to, and were matched by codes for the three questionnaires. For this reason alone, it can be assumed that the two groups differ in 97 some regard. Individuals who volunteer to participate in research studies differ from individ-uals who choose not to (Schumacher & McMillan, 1993). Therefore, it is recognized that the two groups do differ. Perhaps the list of demographic and situational variables used for the comparison was not inclusive enough to demonstrate the differences between the two groups. A more inclusive list of variables may have demonstrated a difference. Characteristics of the Respondents The demographic characteristics of the study sample help to further establish the external validity of the investigation. The profile of the average health care professional in this study is that of a Caucasian, female employed in a hospital setting. She would have earned a college degree and possibly a graduate degree and was most likely between the age of 36 and 55 years. The majority of respondents (79.1%) in this study were female. Given that the group of respondents were primarily nurses, this is not a surprising finding. Nursing is a female dominated profession, accordingly the representation noted here is as expected. Although the sample population may appear biased by the large proportion of females, it does represent a group of health care professionals, the majority being nurses. Given that the majority of respondents in this group of health care professionals are represented by nurses it is not surprising that 37.7% are employed in hospital settings. In general, the representation of employment organizations (i.e., mainly hospitals and government agencies) is in keeping with typical places of employment of health care professionals. The group as a whole was very well educated; 83.6% of the respondents had a college or graduate school degree. Although this highly educated group of health care 98 professionals is not representative of the average North American, they are representative of the health care professional population. Completion of a post-secondary education is a requirement for licensure within health care professions and for practice within North America. In addition, as a part of professionalism, professionals are encouraged by their peers, professional associations and employers to further their education. Continuing one's education is a means of maintaining and enhancing one's professionalism and creating new career opportunities. The average age of the study participants (36-55 years old) is representative of the typical participant of the various studies reviewed in the literature. As such, this representation is taken to be generalizable to similar groups of health care professionals working in North America. In conclusion, the above respondent profile is representative of an average health care professional working in North America. Consequently, the findings generated by this investigation can be generalized to similar populations of health care professionals. Although a response bias is acknowledged due to both the volunteer nature of the survey method used, the results are still applicable to similar groups of health care professionals. Reasons for Participation Five reasons for participation were examined in this study, they are as follows: (a) general interest, (b) need to do your job or volunteer activities differently, (c) confirm what you are already doing is O.K. , (d) required by organization to participate, (e) chance to network with others. 99 The population of health care professionals surveyed in this study reported that 'general interest' was a influential reason for participating in the CTS workshop. This reason for participation was closely followed, in terms of influence on participation, by 'chance to network with others', 'need to do your job or volunteer activities differently', and 'confirmed what you are already doing is O.K.'. The fifth reason for participation, 'required by your organization to participate' was rated the least influential. These findings are in keeping with the results published in the adult education and CPE literature on motivational orientations/ reasons for participation. Reasons for participation most often cited by health care professionals can be grouped into three motivational orientations; cognitive interest, community service, and professional advancement (Dolphin, 1983; Mergener & Weinswig, 1979; O'Connor, 1979; Scanlan & Darkenwald, 1985; Urbano, et al., 1988). 'General interest', as a reason for participation, falls under the motivational orientation of cognitive interest as described by Boshier and Collins (1985). 'General interest' was rated with the greatest influence as a reason for participation. Inherent in being a professional practitioner and as a part of professionalism, there is a desire, and often a social responsibility, to continue to learn and further one's education. As expected, 'general interest' was an influential factor in health care professionals' decisions to participate in the CTS workshop. 'Need to do your job or volunteer activities differently' and 'confirm what you are already doing is O.K.' are both voluntary reasons for participation that are directly related to one's professional practice and improving one's practice. These two reasons would fall under the motivational orientations of professional advancement, or possibly, community service, depending upon the type of organization with which the professional is employed. 100 Professional advancement, as described by Urbano, et al. (1988), is related to occupational and job-related concerns. This orientation does describe the two reasons noted above. Community service has been described as preparing for service to individuals, the community and/or society (O'Connor, 1982; Urbano, et al., 1988). Therefore, wanting to do things differently or wanting to confirm what you are already doing is O.K. could be interpreted as striving to better serve the community in which one works or to better serve one's individual clients. 'Required by your organization to participate' was not a strong influence for participants' participation in the CTS workshops. Again, this is in keeping with results noted in the CPE participation literature. O'Connor (1979, 1982) and Thomas (1986) both found that the motivational orientation, external influence, was not a primary influence on deciding to participate in CPE. These two investigators both used a study population of nurses. Therefore, the results can be compared to the present study which included four health care professional groups; nursing being the largest representation. Consequently, the results obtained in this investigation are similar to results obtained by others in the CPE literature who surveyed comparable groups of individuals for their reasons for participating in CPE. The Relationship Between Reasons for Participation and Application of Learning - Answering the Research Questions The main purpose of this investigation was to explore the linkage between antecedents to educational participation and outcomes. The guiding hypothesis of this study was that of a linkage between antecedents to participation represented by reasons for participation and the outcome, application of learning. 101 The results reveal that there was a relationship between three of the five reasons for participation addressed in this study. There was significant association between three of the four voluntary reasons for participation ('need to do your job or volunteer activities differ-ently', 'confirm what you are already doing is O . K . ' and 'chance to network with others') and subsequent application of learning. There was no significant association between application of learning and one of the voluntary reasons for participation (general interest). A non-significant association was also found between the non-voluntary reason for participation (required by organization to participate) and subsequent application of learning. Although a significant relationship was noted between voluntary reasons for participation and application of learning, it is recognized that this relationship may not hold true for all adult learners. This investigation focused on health care professionals who volun-teered to take part in the P I R E investigation. In this case, the health care professionals are represented by a group of well-educated individuals who are employed as professionals. The level of educational attainment, age, and employment status and volunteer attributes of the sample may have influenced the relationship in question. Voluntary Reasons for Participation and Application of Learning Health care professionals who were influenced to participate in the C T S workshops for the following voluntary reasons: 'need to do things differently', 'confirm what you are already doing is O . K . ' and 'chance to network with others' reported substantial degrees of application of learning. Application of learning was represented by the two statements 'made changes in how you do your work or volunteer activities' and 'increased substance abuse prevention activities'. 102 The demonstration of an association between these two variables (voluntary reasons for participation and application of learning) indicates that there is a link between antecedents and outcomes of participation. The link as demonstrated by this investigation is motivation. Participants who were motivated to participate voluntarily, and for reasons with a specific focus and direct implication to their job, were more likely to have increased their substance abuse prevention activities and made work-related changes. Further to this, it appears that intrinsic motivation, as evidenced by voluntary participation, is a factor in the link. Intrinsic motivation is driven by desires within the individual professional. Examples of such desires are wanting to do one's job or volunteer activities differently or wanting to confirm what is already being done is O.K. When reasons for participation related to intrinsic motivation were influential in the decision to participate, the participants demonstrated greater application of learning. This confirms the ideas presented by Tarmenbaum, et al. (1991) and Baldwin, et al. (1991) who described motivation as an important precursor to the transfer of the training process. These researchers (Baldwin, et al.; Tarmenbaum) also point out that participants are more likely to participate and achieve positive outcomes when there is an element of voluntary influence on the decision to participate. It has been postulated by others (e.g., Baldwin et al., 1991) that if the intrinsic motivation to learn and to do something active with the learning is not present, there is less likelihood that learning will take place. This will result in less application of learning to one's practice or job. As such, the findings of this investigation support earlier work relating motivation to learning outcomes. In this case, the learning outcome is application of learning. Intrinsic motivation helps to explain why there was a non-significant finding for the voluntary reason, 'general interest'. Although this is a voluntary reason it lacks specificity 103 and focus. General interest could be related to a personal interest, social interest, or a professional interest. If general interest influences one to participate in a CPE program, in the absence of intrinsic motivation, application of learning may not occur. In this situation intrinsic motivation is not present to propel the individual towards application of learning. Therefore, a relationship between this voluntary reason for participation and application of learning is not apparent due to the lack of intrinsic motivation. It is noted that a non-significant finding does not indicate that there was not a relationship (Schumacher & McMillan, 1993). Rather, a non-significant finding indicates that further research is needed. Additionally, it is noted that the strength of the link or association cannot be postulated because of the type of statistic used with this data. Hence, a limitation of this study is the use of the chi-square test. The chi-square test is not a strong statistic. Therefore it can only be stated that there is some association between the variables under study; no statement regarding the strength of the relationship can be made. Non-Voluntary Reasons for Participation and Application of Learning The non-voluntary reason for participation, 'required by organization to participate', was not associated with the indicators of application of learning ('increased substance abuse prevention activities' or 'made changes in how you do your work or volunteer activities'). This non-significant finding is evidence that further research is needed in this area. It was anticipated that non-voluntary reasons for participation would be negatively associated with application of learning. As such, greater application of learning would be seen in situations where non-voluntary reasons had only a minimal influence on participation. In this investigation, non-voluntary reasons were considered to be external influences on 104 participation. If a participant is required to participate and is not given a choice in the decision to participation, it is expected that extrinsic motivation may be high but intrinsic motivation to learn and apply learning would be low. This in turn would lead to minimal or no application of learning following the educational program. The participant, if required by external forces to participate, would have no ownership over the decision to participate. In addition, the content of the CTS workshops may not be chosen to meet the individual's needs (personal or professional). This scenario would likely lead to a lack of intrinsic motivation and decreased application of learning. Participant choice in training and learning outcomes has been previously investigated. Both Baldwin et al. (1991) and Hicks and Klimoski (1987) demonstrated that increased choice in participation led to increased motivation and positive outcomes of training. The outcomes of training measured were increased cognitive ability, motivation and learning. A statistically significant relationship between 'required to participate' and subsequent application of learning was not demonstrated in this investigation. The non-significant finding may have been due to the relatively small sample size and decreased variance in the responses to this variable. Of the total number of respondents, 59.6% indicated that 'required by your organization to participate' had no influence on their decision to participate in the CTS workshop. The decreased variance of the responses indicates that less than one half of the participants were not participating because they were required to do so. This is in keeping with the demographic profile exhibited by this sample. The sample population is very well educated. As previously noted, well educated professionals tend to seek out educational opportunities. Furthering one's education is a part of professionalism and is a professional responsibility. 105 When examined, the cross-tabulation of 'required by your organization to participate' and 'increased substance abuse prevention activities' did approach significance. A low indica-tion of 'required by organization to participate' was associated with a high degree of application of learning, but the association was not statistically significant. Perhaps a larger sample size with more variance in the responses would have demonstrated more conclusive results. Improving upon the response rate of the survey would lead to an increased sample size and improved statistical conclusion validity of the results. In addition to increasing the sample size, analyzing other non-voluntary reasons for participation may have resulted in a significant finding. Given that the one non-voluntary reason for participation used in this study resulted in a non-significant association, does, not imply that other non-voluntary reasons for participation would not be associated with applica-tion of learning. The use of only one non-voluntary reasons for participation is a limitation of this investigation. The Influence of Demographic and Situational Characteristics on Application of Learning Few outcomes of CPE stem from the effects of one variable in isolation. One must be aware that there are other variables that are related to application of learning and the learning process. Cafferella (1994) reports that other factors, in addition to reasons for participation, are also related to learning and transfer of learning. Some of these factors are situational such as employer or organizational support, sufficient resources at the workplace, available time to implement, etc. Other factors relate to the program itself; the program content, design, and delivery while still others are personal; personal characteristics and amount of change required. 106 In order to better assess the significance of a relationship between reasons for participation and application of learning, possible confounding factors could have been controlled for in this study. The program design, content and delivery were relatively constant from workshop to workshop so this was only a minor issue. But, the personal and situational factors may have confounded the results. Although these factors were not directly addressed in answering the main question of this study, they were looked at subsequent to the initial data analyses. They were used to answer the second general question; do demographic and situational factors help explain the relationship between reasons for participation and subsequent application of learning? Answering this question helped to better understand the relationship in evidence and to determine other conditions which appear to influence application of learning. No significant differences were noted for application of learning when compared by respondents' demographic characteristics. One would expect that age and level of educational attainment would have lead to some differences in application of learning. It has been previ-ously demonstrated that participant characteristics such as age educational level and employment characteristics are related to motivational orientations (Dolphin, 1983; Scanlan & Darkenwald, 1985; Thomas, 1986). Through the influence of demographic characteristics on motivational orientations, it was expected that these characteristics would have influenced application of learning as well. This investigation did not demonstrate differences in application of learning when compared by demographic characteristics. Further research is needed in view of this non-significant finding. A sample size of 129 may have been too small and may have lacked adequate variability in order for a statistically significant difference to be noted. A larger 107 sample size or a more variable group may have resulted in increased statistical conclusion validity. The degree of application of learning reported by the nursing respondents did vary according to some of the situational variables. There was a difference in the mean ratings of application of learning when compared by situational characteristics. The following situational factors led to differences in application of learning: (a) previous training in substance abuse prevention activities, (b) the usefulness of the workshop, (c) the extent that the workshop was relevant to one's job, and (d) availability of sufficient resources at one's workplace. Although it has been demonstrated in this investigation that reasons for participation are related to application of learning, it has also been established in the literature that situational variables play a role in the process of application of learning (Cafferella, 1994; Kemerer, 1991; Parry, 1990). Respondents who gave moderate to high ratings for the four situational variables noted above; i.e., nurses who indicated that they had substantial training in substance abuse prevention activities, had sufficient resources at their workplace, found the workshop useful, and claimed that the workshop was relevant to their job; indicated greater application of learning than those respondents who indicated low measures for the four situational variables. It was demonstrated in this investigation that application of learning varies with different situational characteristics. Consequently the four situational characteristics may represent confounding factors for the relationship between reasons for participation and application of learning. 108 Limitations The results of this investigation are indicative of a significant relationship between voluntary reasons for participation and application of learning. Despite the significance of this finding, it is recognized that the there are limitations of this investigation. A discussion of the recognized limitations follows. The first limitation of this investigation is the low response rate achieved with this the study sample. The response rate was only 18.8% of the total number of health care profess-ional participants surveyed at the CTS workshops. Despite administrative attempts to use additional mailings and change the coding procedures, the response rate remained relatively low. The low response rate has contributed to a relatively small sample (n = 281). The small sample has resulted in decreased variance of some variables resulting in sub-optimal numbers for strong statistical conclusion validity. The low response rate limits the representation of the study sample. There are four factors that may have contributed to the low response rate. First, participants were asked to respond to three questionnaires (Participant Profile, Participant Feedback, and Follow-up) in order to be included into the study. Filling out questionnaires is time consuming for individuals who have, since the CTS workshop, returned to their jobs. Time constraints may have deterred some individuals from responding to all three question-naires. Second, participants may have forgotten to mail back the questionnaires or misplaced the questionnaires. This may have contributed to a decreased number of responses. The third factor concerns difficulty locating participants. Participants may have moved or changed their place of employment since attending the CTS workshop, resulting in some participants not receiving the Follow-Up Questionnaire. 1 0 9 The fourth possible factor concerns the administrative aspects of coding the participants. Some participants in the CTS workshops generated their own anonymous codes and may have forgotten what their code was by the time they responded to the third question-naire. Therefore, despite participants responding to all three questionnaires, their questionnaires may not have matched. This would lead to invalid questionnaires that did not meet the study criteria. Despite the low response rate, it was demonstrated through a presentation of the demographic characteristics that the average respondent was representative of the health care professional population in North America. Thus, generalizability of the sample to similar health care professional groups can be maintained. It is recognized that the results of this investigation can not be generalized to all health care professionals. The results can only be generalized to similar populations of health care professionals with similar characteristics. A second limitation of this study relates to the length of time that elapsed between the workshop and the Follow-Up Questionnaire. A three to five month period does not allow one to assess how permanent the application of learning made at the work place is. Many changes may have been made soon after completing the workshop, but were these changes permanent and how long did they last for? A longer time period following the completion of the workshop would allow for the assessment of more permanent changes made as a result of application of learning from the workshop. The third limitation identified in this investigation was the use of set questionnaires for both working professionals and volunteers. As such some questions on the questionnaires ask the participant to rate the extent of changes made in one's job or volunteer activities. The wording and grouping of the two situations (volunteers and employed professionals) together 110 is problematic. The questions may have been misinterpreted by participants. This may have influenced the data used in the analyses. A fourth limitation associated with this investigation is the use of only one non-voluntary reason for participation. One non-voluntary reason for participation was used in the data analyses while four voluntary reasons for participation were used. The use of more non-voluntary reasons for participation may have helped in the interpretation of the data or may have resulted in a significant association with application of learning. The final limitation noted is the 'menus' of reasons for participation in the CTS workshops used on the Profile Questionnaire. Participants' responses may be biased by the 'menus' of reasons for participation. As such, participants may indicate reasons as listed in the 'menu' that may not have been reported if answering an open-ended question. In con-clusion, the above limitations are recognized and were considered in the interpretation of the findings and implications of this research. I l l Chapter Six Summary, Implications and Future Directions This chapter provides the reader with a summary of the major findings of this study. The implications of the most salient findings to the practice and research of adult education will then discussed. Lastly, future directions for this area of study will be discussed. Summary of Major Findings The main purpose of this study was to determine if there was a linkage or relationship between reasons for educational participation and subsequent application of learning. The context of the study was that of a continuing professional education workshop for health care professionals in the area of substance abuse prevention. The major findings of this study revealed a relationship between voluntary reasons for participation and subsequent application of learning. More specifically, a relationship was demonstrated between three of the four voluntary reasons for participation surveyed and application of learning. The three voluntary reasons for participation associated with application of learning are: (a) need to do job or volunteer activities differently, (b) confirm what you are already doing is O.K., and (c) chance to network with others. Examination of the chi-square tests for association revealed a positive direction for the association. As the influence of the reason for participation became stronger, the extent of the subsequent application of learning was greater. Participation, influenced by motivation with a specific focus and voluntary locus, appears to lead to greater application of learning. 112 Additional analyses of the health care professional sub-groups who comprise the combined sample of this investigation were carried out. It was found that the sample of nurses, due to their large numbers (n = 129), appeared to influence the combined sample. In order to better understand the relationship between reasons for participation and application of learning, subsequent analyses of the data from the sample of nurses were carried out. These analyses revealed that factors, in addition to reasons for participation, influence application of learning. These factors were identified by one-way ANOVAs of application of learning by demographic and situational characteristics. Application of learning varied when compared by the following situational variables: (a) previous training in substance abuse prevention activities, (b) usefulness of the workshop, (c) relevance of the workshop to one's job, (d) sufficient resources available at one's organization. The above situational factors lend further insight into the issue of application of learning. But the finding of a relationship between voluntary reasons for participation and application remains the integral finding of this investigation. Implications The findings of this study are encouraging as they provide evidence of a linkage between reasons for participation and application of learning. This investigation helps lay the groundwork for further research on the relationship between voluntary reasons for participation and application of learning. In addition, the findings of this research contribute to the understanding of the entire learning process; starting with antecedents to participation and ending with outcomes (application of learning). The relationship between antecedents and 113 outcomes, as demonstrated in this investigation, help the adult educator put the process of learning into perspective. The importance of participant motivation to learn and apply what was learned in the context of CPE, and subsequent application of learning has been demonstrated. Motivation, measured here by the influence of reasons for participation, is a precursor to application of learning. Despite the presence of other facilitators that may enhance application of learning, the motivation to learn and apply the learning back at the work-site must be present. If this motivation is absent, it is unlikely that application of learning will take place. The decreased likelihood of application of learning in cases where intrinsic motivation was not an influential factor in deciding to participate is of interest. It is of particular interest with CPE and particulary, mandatory CPE. Mandatory CPE is a requirement of many health care professional associations and professional colleges for licensure/re-licensure. Mandating professionals to participate in CPE is viewed as a means of keeping professionals up-to-date with new knowledge. As such, it is implied that mandatory CPE results in application of learning and improved practice. Hence, if this relationship were clearly established, what would be the purpose of mandatory CPE if professionals lacked intrinsic motivation? If pro-fessionals are motivated to attend because of external pressure, but lack intrinsic motivation, they would be less likely to use what was learned. If learning is less likely to take place when the motivation to learn and apply it is absent, is there any point in having mandatory CPE or employer required participation in workshops? This is a difficult question to answer because the argument that mandatory CPE and required participation are better than 'having nothing at all' is prominent and realistic. Adult educators can not assume that learning and subsequent and application of learning will take place when intrinsic motivation is lacking. Instead, when intrinsic motivation is lacking, required participation should be viewed as a 114 situation in which optimal learning and application of learning will likely not take place. Rather than focusing on participation as a marker or measure of CPE, perhaps we should focus on motivation or application of learning. A major implication from this research involves the ensuing responsibility of the CPE/adult educator to develop strategies to enhance and instigate motivation in participants. The development and enhancement of intrinsic motivation is needed in order to promote and encourage application of learning. Increasing motivation in participants before or during the workshop may be what is needed to maximize application of learning following the completion of a workshop. Assessing participants' motivation, in particular intrinsic motivation, could be included in program planning at the needs assessment, content planning, delivery, and marketing stages. Educators should not assume that all participants are motivated. As demon-strated in this study and elsewhere in the participation literature, participants attend CPE for a variety of reasons. If voluntary reasons with a specific focus are not the influential reasons for attending the educational program, educators could address increasing participants' motivation as part of the program curriculum. Another implication of this research involves that of training costs and expenses. Is it financially feasible for organizations to spend large sums of money on employees' training and education if the employees are not motivated by voluntary reasons to learn and apply learning? When employers send employees to educational events it is expected that the work organization will benefit through the employees' learning of new skills and knowledge. In other words, it is expected that the employees will apply their learning back at their present jobs. In cases such as these it would be prudent to assess participant motivation prior to the workshop. If motivation is lacking, increasing participants' motivation during the workshop would be necessary in order to encourage application of learning. 115 In the above discussions on implications it is apparent that there is a common thread between the issue of mandatory CPE, required participation and training costs. The common thread is motivation. Participants must be motivated to learn and apply their learning in order for application of learning to take place. When application of learning is a stated goal of a workshop, increasing motivation should be planned as part of the curriculum. But, it should be noted that not all education events are intended to result in application of learning. Increasing motivation could start at the marketing stage, be incorporated into the curriculum and carry on throughout the program delivery. Motivation to learn, and apply learning, is necessary at all stages of the learning/participation process. Howard (1989), in his comprehensive expectancy motivation model, postulates just this. A high level of motivation must be present in the participant at the pre-learning, learning and post-learning stages in order for application of learning to occur. An understanding of the relationship between reasons for participation and application of learning is also of interest at the evaluation stage of adult education programs. If evaluators are cognisant of the link between reasons for participation and application of learning, both will be taken into account during the evaluation process. The effectiveness of a program cannot be determined when based upon program outcomes alone. Reasons for participation should be assessed prior to assessment of program outcomes (i.e., application of learning). If voluntary reasons for participation have influenced participants to attend a program, application of learning would then be an appropriate outcome to use as a measure of program effectiveness. But, it should be recognized that outcomes such as application of learning should not be used as measures of program effectiveness if the participants are not motivated to make changes prior to, or during, the program. 116 The present research also has implications for research design. The fact that self-reporting was used to collect the data utilized in this research is one limitation of the design. As previously discussed, when using self reported data, the researcher must assume that responses obtained are 'truthful' and accurately represent the situation under investigation. Perhaps stronger conclusions could have been drawn with the use of observations to supplement the self-reported data. In addition, corroboration with others (i.e., employers, peers, etc.) regarding the degree of application may help to increase the validity of the reports. Therefore, further research in this area could utilize both qualitative and quantitative methodology to increase the validity of the data collected. This would, in turn, provide more evidence to support the strength of the relationship. Future Directions This investigation has helped to provide further insight into an area for which there is minimal research. A significant relationship between voluntary reasons for participation and application of learning has been demonstrated. Further research is needed in this area to help substantiate the relationship. Improvements upon the design used in this investigation would help to strengthen the results. First, control of possible confounding variables (demographic characteristics, situational variables) could be implemented. This would help to isolate the relationship between the independent and dependent variables. Second, combining qualitative and quantitative data on both reasons for participation and application of learning would help to substantiate and provide further insight into the relationship. Qualitative data could be used to elaborate upon reasons for participation and application of learning. 117 A third modification for future research would be to extend the length of time between data collections or include a second Follow-Up Questionnaire one year post-workshop. This would allow for assessment of more permanent measures of application of learning. In addition one would be able to determine if the relationship is upheld over time. A fourth modification involves using a larger sample population. This would allow for more conclusive results. Improving upon the matched response rate of the survey would allow for a larger sample population. In order to improve upon the response rate, coding of the participants would need to be done in a more systematic manner. Rather than having participants generate their own codes, assigning codes to participants may help improve the number of matched questionnaires. Additional mail-outs of the Follow-Up Questionnaire and reminders to the participants to complete the questionnaire in a more systematic manner may help to increase the response rate. Fifth, in addition to using a larger sample population, a more diverse group of individuals could also be used. This would allow for increased generalizability of the results and would also allow one to check if the results are upheld with different groups of adult learners. Last, surveying the participants on the influence of additional non-voluntary reasons for participation would be useful for the data analyses. This would provide more insight into the relationship, if any, between non-voluntary reasons for participation and application of learning. As noted above, it is recognized that further research is needed in this area. 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Adult Education Quarterly. 41. 29-42. Vroom, V.H. (1964). Work and motivation. New York: John Wiley. Waddell, D.L. (1993). Why do nurses participate in CE? A meta-analysis. Journal of Continuing Education in Nursing. 24. 52-56. Wergin, J.F., Mazmanian, P.E., Miller, W.W., Papp, K.K. and Williams, W.L. (1988). Journal of Continuing Education in the Health Professions. 8. 147-159. Williamson, J.W., Aronovitch, S. & Simonson, L. (1975). Health accounting: an outcome-based system of quality assurance: illustrative application to hypertension. Bulletin of the NY Academy of Medicine. 51. 727-738. Appendix A CSAP Data Log 125 03 cr u u. 10123/101 I ID12/1D1 Percent matched Profile. Feedback, and Follow-up forms (valid Id s) 1 10123 i id's) | Percent matched Profile. Feedback, and Follow-up forms (valid Id s) 1 u. lentiflcation numbers _J Matched Profile & Feedback 4 Follow-up forms I >rms (out of Participants) 1 Percent matched Profile and Feedback forms (valic Percent matched Profile. Feedback, and Follow-up forms (valid Id s) 1 1012 lentiflcation numbers _J Matched Profile & Feedback forms 1 g a * o o u. Matched Profile & Feedback 4 Follow-up forms I >rms (out of Participants) 1 Percent matched Profile and Feedback forms (valic Percent matched Profile. Feedback, and Follow-up forms (valid Id s) 1 POST lentiflcation numbers _J Feedback forms 1 1 Matched Profile & Feedback forms 1 Matched Profile & Feedback 4 Follow-up forms I >rms (out of Participants) 1 Percent matched Profile and Feedback forms (valic Percent matched Profile. Feedback, and Follow-up forms (valid Id s) 1 5 Participants Profile Forms Profiles with valid Id Feedback forms 1 1 Matched Profile & Feedback forms 1 Matched Profile & Feedback 4 Follow-up forms I a * o Percent matched Profile and Feedback forms (valic Percent matched Profile. Feedback, and Follow-up forms (valid Id s) 1 Consent forms Pre-1994 workshops PRE Event cod Participants Profile Forms Profiles with valid Id Feedback forms 1 1 Matched Profile & Feedback forms 1 Matched Profile & Feedback 4 Follow-up forms I Percent F< Percent matched Profile and Feedback forms (valic Percent matched Profile. Feedback, and Follow-up forms (valid Id s) 1 Consent forms Pre-1994 workshops a. LEGEND i I u 1 L U ! 1 1 FO a. PRE c POST 1012 2 10123 i a U . ID12/1D1 10123/101 u i Location I ! i i i 1 i i ! i I i I ! i 1 1 1 i 1 1 i i ; i i | ! 1 I 1 ! ! i ' i j ! i M l ! : : • i : : : i : j j ^ • i • ' : : i ; i ! i i ! '• ; • : ; ; I 1 i i i i ' ' ! ! 1 I ' : , i Q n JS u m OS O >J «J •U (0 Q CU < in u a o < UL O z o Z Ui 0 z z 1 I -V) UJ p <r> V J —I Ifl'fl Q 5 ; a ° ta ui 2 C ^ a> SS"o o o o Q C M S w N ffl n N O in + n i r — > -Ui> V , ' " " J C 5 •> 2 •* «"» 5r 5 • 3 -8 C M * -8 ea p S> 8 = J : C/3 Z «•» 0 9 CM «o cclo. 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C O T -rt 00 to I O CO n cn r > t o r— CM CO M" CM CM rt rt rt T t o rt 00 t o C O C M t o OO T M" 9 = C M C M C M r ~ |MENTAL HEALTH SPECIALISTS - COUNSELLORS £ C M •>«• i n C M CO n « t o r*. CM CO T CO C M rt rt U9 t o rt 00 t o C O C M t o t o t o CO CM M- w cc L U o S < U I C M o o T — C M |MENTAL HEALTH SPECIALISTS - COUNSELLORS ( N C M m h -C N C O C N i n co i n T m co C N t o C O C M t o 00 t o c n rt ft : N i C O : C M : t n co C M t o o 00 t— |MENTAL HEALTH SPECIALISTS - COUNSELLORS ^ ^ M n T i n t o C O o - C M C O T i n 8 CO I t-C 0 O r- C M C O |MENTAL HEALTH SPECIALISTS - COUNSELLORS | Location New Orleans Phoenix iPueblo w fZ £ E nj 2 c 8 J C C L 8 V) m E o x: C O i o C O n Q S. B TO ra to t-J? 3 e CU •5 a. cc CU O c -o •5 o a o •— c "ra O 3 CO O 3 CO M" cn cn T— _ l o Ul a. CO X t-_ l < Ul Location | Hffltford Washington 1 c o B) cz n V ) C O "!5 o S 3 co 7a O 3 C O cn cn |MENTAL HEALTH SPECIALISTS - COUNSELLORS § 1 I 1 i oi § I S 1 X -1 < z UJ £ X 2 t i j 1 1 1 1 ! ! CO X Z i Appendix B Conceptual Framework 130 Figure 1. Application Process Framework. As adapted from the PRECEDE Framework, this Framework shows 5 factors influencing application: Educational Program, Innovation, Predisposing, Enabling and Reinforcing Factors. r \ ' Predisposing Factor Reinforcing Factor V ) Context Appendix C Data Collection Instruments 132 Event Code Participant Code CENTER FOR SUBSTANCE ABUSE PREVENTION TRAINING SYSTEMS (CTS) (INSERT NAME OF TRAINING HERE) PARTICIPANT PROFILE QUESTIONNAIRE 1. To what extent were you informed about the purposes of this workshop? Circle one number. 1 2 3 4 5 6 7 8 9 10 Not at all Completely 2. To what extent did each of the following influence you to come to this workshop? Circle one number for each item. No influence Extremely influential a. General interest 1 2 3 4 5 b. Need to do your job or volunteer activities differently 1 2 3 4 5 c. Required by organization to participate 1 2 3 4 5 d. Confirm what you are already doing is Okay 1 2 3 4 5 e. Chance to network with others 1 2 3 4 5 f. Other: 1 2 please specify 3 4 5 3. To what extent do you expect that this workshop will make a difference in the way you do your job or volunteer activities? 1 2 3 4 5 6 7 8 9 10 No difference Substantial difference 4. Please provide the following information about yourself: a. To what extent have you had previous training or education in substance abuse prevention? • Not at all • Very little • Some • A lot • Extensive b. To what extent have you worked or volunteered in the field of substance abuse prevention? • Not at all • Very little • Some • A lot • Extensive c. Which of the following is the primary focus of your substance abuse activities? • Prevention/education • Both prevention and treatment • Treatment/intervention • Other: please specify d. Are you part of an organized prevention coalition or partnership in your community? • No • Yes 133 4. To what extent did this workshop provide the following? Circle one number for each item. Not enough On target Too much a. Practical examples 1 2 3 4 5 b. Time for discussion 1 2 3 4 5 c. Practice time 1 2 3 4 5 d. Opportunity to consider what will help or stop you from applying your learning 1 2 3 4 5 e. Help in planning for application of learning 1 2 3 4 5 f. Other Dlease specify 1 2 3 ' 4- 5 5. To what extent would you describe your experiences in this workshop as follows? Circle one number for each item. Not at all Completely a. Relevant to your job 1 2 3 4 5 b. Possible to apply 1 2 3 4 5 c. Advantageous over current practices 1 2 3 4 5 d. Met your needs 1 2 3 4 5 e. Met the needs of your organization/community 1 2 3 4 5 f. Other please specify 1 2 3 4 5 Overall, to what extent did the workshop lead to the following? Circle one number for each item. Not at all Substantial a. Increased knowledge or skills 1 2 3 4 5 b. Encouraged links with others for support 1 2 3 4 5 c. Modified beliefs or feelings 1 2 3 4 5 d. Confirmed what you were already doing is okay 1 2 3 4 5 e. Offered insights into doing your job or volunteer activities differently 1 2 3 4 5 f. Prepared you to apply learning 1 2 3 4 5 g- Other please specify 1 2 3 4 5 7. To what extent are you likely to do the following as a result of this workshop? Circle one number for each item. Not at all Extremely a. Share information with others 1 2 3 4 5 b. Make changes in how you do your work or volunteer activities 1 2 3 4 5 c. Use materials from the workshop 1 2 3 4 d. Contact others for support to apply learning 1 2 3 4 5 e. Advocate for your organization to apply ideas from the workshop 1 2 3 4 5 f. Get more training or information on topic 1 2 3 4 g- Increase substance abuse prevention activities 1 2 3 4 h. Other: 1 2 3 4 please indicate 134 8. To what extent do you expect this workshop will make a difference in the way you do your job or volunteer activities? 1 2 3 4 5 6 7 8 9 10 No difference Substantial difference 9. To what extent do the following exist in your organization or community to help you apply your learning? Circle one number for each item. Not at all Substantial a. Sufficient resources 1 2 3 4 5 b. Encouragement from others 1 2 3 4 5 c. Opportunity to apply learning 1 2 3 4 5 d. Authority to act or apply learning 1 2 3 4 5 e. Support of organization for changes implied by this 1 2 workshop 3 4 5 f Other 1 2 please specify 3 4 5 10. To what extent do you feel able to apply your learning from this workshop to your job or volunteer activities? Circle one number. 1 2 3 4 5 6 7 8 9 10 Not at all Completely 11. Please add any additional comments or suggestions you have about the workshop or your experiences. c:\wp51 \osaps\instru\022894 pst 135 Event Code Personal Code CTS FOLLOW-UP QUESTIONNAIRE What changes related to substance abuse prevention have you made in your job, organization or community, as a result of this workshop? « -2. Overall, how would you rate the usefulness of the workshop? Circle one number. 1 2 3 4 5 6 7 8 9 10 Not at all Completely 3. To what extent would you describe your experiences in the workshop as follows? Circle one number for each item. Not at all Completely a. Relevant to your job 1 2 3 4 5 b. Possible to apply 1 2 3 4 5 c. Advantageous over previous practices 1 2 3 4 5 d. Met your needs 1 2 3 4 5 e. Met the needs of your organization / community 1 2 3 4 5 f. Other 1 2 please specify 3 4 5 136 4. Overall, to what extent did the workshop lead to the following? Circle one number for each item. Not at all Substantial a. Increased knowledge or skills" 1 2 3 4 5 b. Encouraged links with others for support 1 2 3 4 5 c. Modified beliefs or feelings 1 2 3 4 5 d. Confirmed what you were already doing is okay 1 2 3 4 5 e. Offered insights into doing your job or volunteer 1 2 activities differently 3 4 5 f. Prepared you to apply learning 1 2 3 ' 4 5 9- Other: 1 2 please specify 3 4 5 5. To what extent did you do the following as a result of the workshop? Circle one number for each item. Not at all Substantial a. Shared information with others 1 2 3 4 5 b. Made changes in how you do your work or 1 2 volunteer activities 3 4 5 c. Used materials from the workshop 1 2 3 4 5 d. Contacted others for support to apply learning 1 2 3 4 5 e. Advocated for your organization to apply ideas from 1 2 the workshop 3 4 5 f. Got more training or information on topic 1 2 3 4 5 g- Increased substance abuse prevention activities 1 2 3 4 5 h. Other: 1 2 Dlease specify 3 4 5 6. To what extent did the workshop make a difference in the way you do your job or volunteer activities? 1 2 3 4 5 6 7 8 9 10 No difference Substantial difference 7. one To what extent do the following exist in your organization or community to help you apply your learning? Circle number for each item. Not at all Substantial a. Sufficient resources 1 2 3 4 5 b. Encouragement from others 1 2 3 4 5 c. Opportunity to apply learning 1 2 3 4 5 d. Authority to act or apply learning 1 2 3 4 5 e. Support of organization for changes implied by the 1 2 workshop 3 4 5 f. Other: 1 2 Dlease specify 3 4 5 1 3 7 To what extent do you feel able to apply your learning from the workshop to your job or volunteer activities? Circle one number. 1 2 3 4 5 6 7 8 9 10 Not at all Completely 9. Please add any additionalcomments or suggestions you have about the workshop or your experiences. 38 Event Code Participant Code C E N T E R FOR S U B S T A N C E A B U S E PREVENTION TRAINING S Y S T E M S (CTS) PARTICIPANT F E E D B A C K QUESTIONNAIRE What are likely changes related to substance abuse prevention you may make in your job, organization or community, as a result of this workshop? 2. Overall, how would you rate the usefulness of this workshop? Circle one number. 1 2 3 4 5 6 7 8 9 10 Not at all Completely 3. Overall, how would you rate the following about this workshop? Circle one number for each item. Extremely poor • Excellent a. Teaching methods or processes 1 2 3 4 5 b. Organization, schedule, or flow of activities 1 2 3 4 5 c. Cultural competence of workshop content and process 1 2 3 4 5 d. Cultural competence of trainers 1 2 3 4 5 e. Other: 1 2 please specifiy 3 4 5 139 e. Which type of organization are you primarily representing at this workshop? Please check the one best answer • Government • Education • Not representing an organization • Law enforcement/legal • Religious • Other: • Hospital/healthcare • Volunteer organization please specify • Private practice • Business f. Does anyone, other than yourself, expect something from you as a result of attending this workshop? • No • Yes: Please explain g. Did anyone accompany you to this workshop? • No, came alone • Yes, as part of a team • Yes, with others, but not, as a team • Other: please specify h. How are your expenses for this workshop being paid? • By you • Shared between you and organization • By supporting organization, • Other: government etc. please specify i. Your sex: • Male • Female j . Your age: • 25 or less • 26 - 35 • 36-45 • 46-55 • over 55 k. The highest level of formal education you have reached: • Grade school or some high school • College degree • Completed high school • Graduate school/graduate degree • Some college or a trade/vocational school I. Based on the categories below, how would you identify your race or ethnicity? • African American • Caucasian • American Indian or Alaskan Native • Asian American or Pacific Islander • Hispanic/Latino • Other: please specify m. Based on your answer to question "4-1" above, how do you further define your race or ethnicity? final:6/27/94 Appendix D Frequency Distributions of Independent and Dependent Variables Table Dt Frequency Distribution of Variable - 'General interest' 141 Value Frequency Percent 1 - No influence 2 0.75 2 8 2.98 3 45 16.79 4 102 38.06 5 - Extremely influential 111 41.42 TOTAL 268 100.00 Table D2 Frequency Distribution of Variable - 'Confirm what you are already doing is O.K.' Value Frequency Percent 1 - No influence 47 18.08 2 35 13.46 3 74 28.46 4 72 27.69 5 - Extremely influential 32 12.31 TOTAL 260 100.00 Table D3 Frequency Distribution of Variable -'Need to do your job or volunteer activities differently' Value Frequency Percent 1 - No influence 19 7.39 2 24 9.34 3 70 27.24 4 84 32.68 5 - Extremely influential 60 23.35 TOTAL 257 100.00 142 Table D4 Frequency Distribution of Variable - 'Required by organization to participate' Value Frequency Percent 1 - No influence 155 59.61 2 30 11.54 3 30 11.54 4 21 8.08 5 - Extremely influential 24 9.23 TOTAL 260 100.00 Table D5 Frequency Distribution of Variable -'Chance to network with others' Value Frequency Percent 1 - No influence 23 8.81 2 23 8.81 3 52 19.92 4 86 32.95 5 - Extremely influential 77 29.50 TOTAL 261 100.00 Table D6 Frequency Distribution of Variable - 'Increased substance abuse prevention activities' Value Frequency Percent 1 - No at all 45 17.44 2 43 16.66 3 64 24.81 4 76 29.46 5 - Substantial 30 11.63 TOTAL 258 100.00 143 Table D7 Frequency Distribution of Variable - 'Made changes in how you do your work or volunteer activities' Value Frequency Percent 1 - Not at all 36 13.23 2 48 17.65 3 85 31.25 4 80 29.41 5 - Substantial 23 8.46 TOTAL 272 100.00 

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