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The development and evaluation of a preceptorship program using a practice development approach.

INTRODUCTION

Nursing workforce pressures have resulted in increased numbers of enrolments in undergraduate programs and increased numbers of beginning level registered nurses entering practice. The preceptorship model is widely used in nursing and midwifery for supporting beginning level practitioners. It is now the case that nurses and midwives, irrespective of their years of experience or educational qualifications, can be required to supervise and support undergraduates, trainee enrolled nurses, refresher course nurses and new staff for a significant part of each working week.

This paper will report on a Practice Development initiative that was undertaken to develop and evaluate a Preceptorship Workshop for nurses and midwives. Responding to concerns of key stakeholders in the preceptor program at this research site, a new workshop was developed that drew on a Practice Development framework.

The Practice Development Unit-Nursing and Midwifery is a 'new look' Education Unit for the area health service where the study took place. Practice Development is a term historically used to describe a range of different approaches to improving health care. In the context of this research, we rely on Manley et al (2008) who claim key concepts underpinning Practice Development, particularly those with an emancipatory intent. They state 'emancipatory PD explicitly uses critical social scientific concepts on the basis that the emphasis on the development of individual practitioners, cultures and contexts within which they work, will result in sustainable change' (p. 1). Further, the concepts rely on a willingness to participate in critical conversations and to pursue new knowledge in order to challenge embedded individual or group 'taken for granted understandings' of the way things are. In line with stated values we are committed to life-long learning and professional nursing and midwifery practice of the highest standard. In accordance with these values we support and promote the provision of high quality clinical placements for nurses and midwives from the university and polytechnic. These places have increased threefold in the past four years commensurate with rises in the numbers of places offered for undergraduate nursing to meet the projected shortfall of nurses.

The following assumptions informed the design of the Preceptor Workshop:

* Facilitation/teaching is an integral component of the role of professional nurses and midwives. Therefore, qualified nurses and midwives are not learning from scratch.

* The role of one to one preceptorship taken by clinicians is primarily one of demonstrating and explaining nursing and midwifery. It is more important to demonstrate high standards of nursing and midwifery practice than to have advanced knowledge of educational theory.

* Experiential learning is the most effective way to encourage critical reflection on and in practice to build a knowledge base and promote confidence amongst preceptors.

Guided by a Practice Development framework, the workshop is collaborative and interactive. A series of exercises engage participants and contributes to the agenda as the day progresses. Workshop content included discussion framed by reflections associated with three guided pre-readings; reflections on preceptor experiences; scenario based group work; and interactive sessions exploring feedback, competency based assessment and clinical decision making. Given the workshop departed from the more traditional structure of other courses across the State the decision was made to use an evaluation tool to measure change in participants' perception of their confidence and ability across the day. This enabled the team to be flexible locally in the style of delivery and still meet our statewide responsibility for standardisation of subject content. The evaluation was therefore able to include narrative and critical elements aligned with Practice Development approaches and meet clinical governance requirements.

LITERATURE REVIEW

A preceptor is a practicing nurse who provides individual clinical supervision and teaching predominantly on a one to one basis whilst undertaking a normal clinical workload (Health Workforce Australia 2010). Preceptors foster professional socialisation and act as role models with the aim of assisting beginning level practitioners in the transition to their role. The preceptor role is usually assumed for a period of time, in addition to existing clinical responsibilities (Bourbonnais and Kerr 2007; Mills et al 2005). Findings from the literature suggest that the role of preceptor can be quite varied (Usher et al 1999; Dibert and Goldenberg 1995) and there is a need for further research in this area (Bourbonnais and Kerr 2007).

Positive characteristics of preceptors include good communication skills, and being both approachable and supportive. Factors identified as important to the preceptor role include understanding the theoretical components of the student curriculum; maintaining current knowledge base; providing feedback; and assessment of practice (Heffernan et al 2009). The success of preceptorship is impacted by the welcome and orientation; providing clinical skills and experience; and linking theory to practice (Myall et al 2008). Strategies that facilitate preceptee learning include taking a 'hands on' approach; sequencing tasks; providing illustrations; assessment; observation; conversing and reflecting; and having a questioning attitude (Bourbonnais and Kerr 2007; Ohrling and Hallberg 2001).

The preceptor role is quite complex and on a background of a busy acute care environment, can require development of key skills. The literature highlights the importance of preparation and support for the preceptor role in order to facilitate engagement and skill development (Hallin and Danielson 2009; Charleston and Happell 2005; Gibson and Hauri 2000; Allen and Simpson 2000; Dibert and Goldenberg, 1995). Support for undertaking the preceptor role and preceptor programs themselves will vary between sites and individual settings within those sites. Studies report on preceptors' perceptions of levels of support--in general (Hallin and Danielson 2009; Fox et al 2006); by co-workers (Dibert and Goldenberg 1995) and by faculty (Gibson and Hauri 2000). Other studies report that preceptors did not perceive adequate support or recognition--in general (Myall et al 2008; Allen and Simpson 2000); from administration and faculty (Bourbonnais and Kerr 2007; Dibert and Goldenberg 1995); and from educators and co-ordinators (Usher et al 1999). Effective preceptorship can be adversely impacted by high workload, lack of time and high student numbers (Hallin and Danielson 2009; Myall et al 2008; Allen and Simpson 2000). In addition, the frequency of taking on a preceptor role and resultant fatigue can have a negative impact on preceptors, leading to preceptor burnout (Bourbonnais and Kerr 2007; Dibert and Goldenberg 1995). Other issues identified within the literature include the need for increased focus on values in nursing practice (Ohrling and Hallberg 2001); the lack of guidance from experienced preceptors (Bourbonnais and Kerr 2007); a lack of constructive feedback; and linking research findings to practice (Hallin and Danielson 2009). Preceptor programs can provide support to the role by allowing time to share experiences and demonstrate organisational commitment to the role.

There is a large body of literature related to the preceptorship role that focuses on the knowledge, skills and quality of support required from clinical nurses. However such discussions do not address the tensions that arise for nurses acting in the role when their focus of the working day is providing high quality safe patient care. We argue that clinical nurses often possess the knowledge and skill required yet are not routinely provided opportunities to discuss, reflect, and further develop their role, taking into account the local context, informed by personal and group experiences. Hence the workshop and analysis of workshop participation with a focus on sharing and exploring experiences, whilst also providing content related to the role that participants can critically explore and consider applying in practice. It is our contention that the preceptor workshop is just one part in the on-going preparation and support for preceptors. In a Practice Development environment we encourage preceptors to learn in practice, critically reflect and apply new knowledge, engaging effectively with the university requirements and promoting a learning culture.

METHOD

Aim

The aim of the study was to develop and evaluate a Preceptorship Workshop for nurses and midwives. The specific objectives were to:

* explore nurses' and midwives' attitudes, perceptions and concerns about being a preceptor; and

* measure changes in participant self assessment of knowledge and ability to undertake preceptorship pre and post attendance at the preceptor workshop.

Findings from the study were used in two ways. Firstly they were used in each workshop to help focus the day and respond to the particular needs of participants. Secondly quantitative data was used to measure change in ability and confidence during the workshop.

Design

Following emancipatory Practice Development principles, where participation and critical dialogue is central, a methodology was chosen where participants were perceived as holders of knowledge and our aim was to strengthen the potential of all concerned (McCormack et al 2004).

Participants

All nurses and midwives who enrolled in the one day preceptor workshop delivered monthly in the period from July-December in 2009 were invited to participate. Ninety three individuals participated in the workshop and all contributed data to the research.

Data Collection

Demographic data was collected from participants and included the clinical area in which they worked; highest qualification; time worked as a nurse or midwife; and age group. A pre and post program evaluation comprised a self-assessment of learning outcomes from the program and the opportunity for general comments. The evaluation was completed at the beginning of the workshop and at the end of the day. Respondents were asked to self assess their ability, understanding and knowledge on a five point Likert scale with ratings from low to high. Six statements were used which represented the intended learning outcomes of the program. In keeping with the methodology, data from Practice Development exercises were used to generate data about the attitude, perceptions and concerns nurses and midwives have of preceptorship and about being a preceptor.

Participant data was also collected using an established Practice Development activity during the opening and focusing exercise, where all participants were asked to write on post-it notes their 'hopes'; 'fears' and 'expectations' for the day. Instructions were that hopes included what it was participants hoped to achieve by attending the workshop; fears were worries or concerns they may have about the program and/or the skills and knowledge they were to gain and put into practice; expectations included what participants considered the likely outcomes of their attendance and how they might practice their newly developed skills and knowledge. Post-it notes were placed by participants on pieces of larger paper to allow grouping according to themes.

Analysis

Qualitative findings were thematically analysed during the workshop as part of the Practice Development process. The themes were confirmed by participants in the workshop through discussion ensuring collaborative analysis and allowing checking with participants for meaning and further elaboration. Lather (1991:67) describes such a step of 'recycling description, emerging analysis and conclusions' to participants as enabling face validity to be established. Quantitative data from the pre and post program evaluation was entered into the statistical software package SPSS for analysis. Descriptive statistics were used to provide summaries of the data and allow for the presentation of the basic features of the data in a simple and manageable form (Beanland et al 1999). A paired samples t-test was used to compare the means of related data and allowed for understanding the impact of the intervention in the group (Streiner and Norman, 2008). The test was conducted to compare participants self ratings of confidence, knowledge and ability to undertake the preceptor role. Statements were guided by the workshop learning outcome domains. The statements were ranked by respondents using a five point Likert scale from minimal to high immediately prior to, and on completion of the workshop (see table 1 for statements).

Ethics

Formal ethics approval from the Human Research Ethics Committee (H10667) was obtained before data collection commenced. Participants were provided with written information outlining the research as part of the pre workshop information package distributed approximately four weeks prior to each program. Opportunity was provided at the beginning of the workshop to clarify participation and allow any questions to be answered. Participant responses were anonymous and refusal to participate in the research did not alter the level of participation in the program itself. All research participants signed a written consent.

RESULTS

Demographics

Table 2 contains general demographic information relating to participants.

The lower number of males to females and age ranges at both the younger and relatively mature ends of the employment age scales are consistent with the nursing demographics for the area. The relatively equal numbers of those who had preceptor preparation and those without can be explained by the two age groups with high representation. Further, the workshops are designed for groups of people with a range of education and experience.

Qualitative Results

Pre workshop hopes reflected a desire to supervise and support students; to gain knowledge and understanding about the role; to develop facilitation skills and become well respected preceptors. The fears centred on the interactive nature of the workshop, the workload involved in precepting and fear of failure as a preceptor. Expectations for the day included issues participants wanted to be covered in the program and skills that would be acquired.

The post workshop comments reflected a very positive attitude to the day. Participants' confidence increased regarding their knowledge and ability to provide feedback as well as to facilitate and support other nurses. Despite some fears expressed in the pre-workshop data that the day would be too interactive, there were many positive comments about the quality of the discussion and the interactive nature of the workshop. Table 3 gives examples of the themes that emerged and the responses both pre and post workshop.

Pre and Post Evaluation Survey

Quantitative findings support findings discussed above and are shown in tables 4 and 5 below.

The paired samples t-test comparing self-ratings of confidence, knowledge and ability to undertake the preceptor role demonstrates a significant difference across all domains. The evaluation utilised has supported the hypothesis that participation in the workshop would increase clinical nurses' confidence, knowledge and skill development in the area of preceptorship. In addition, findings suggest that participation in the workshop has provided participants with valuable insights into preceptorship and the application of underlying principles. Of note, statement four: 'My knowledge of the requirements of my role as a preceptor in relation to the structure of a range of nursing programs' demonstrates the highest shift in self assessment.

Limitations

This study was confined to one setting and analysis of data was contextually situated in time, place, culture and situation, therefore findings cannot be generalised. However, the work provides insights for others to reflect on and consider relevance for their own settings. As the pre and post test data occurred on the same day with nurses and midwives who attended holding an expectation of improvement in skills, knowledge and ability, it is possible the results could have been affected. A follow up to the post test at a longer time interval would assist in further analysis.

DISCUSSION

Results of the study indicate that participants wanted to provide quality experiences for learners and to increase their knowledge and skills as effective preceptors. They recognised their professional responsibility to those entering the profession and were committed to the development of these learners. In addition, participants were able to identify areas for their own development. At completion of the program, participants assessed themselves as having increased knowledge and skills of preceptorship including the expectations for the role and tools they will be able to draw upon in supporting preceptees. The program emphasises the facilitation role of preceptors and that preceptees are adult learners who also have a responsibility for their own learning. However, there is also an emphasis on the development of a culture that fosters and supports learning and the role participants have in supporting this.

Key elements of Practice Development are facilitation and participation of people, evidence based practice and critical enquiry. Practice Development has in common with emancipatory research the desire to be informed by, and respond to, the experiences and needs of the people involved, providing them with an opportunity to take control and generate understanding from doing. This project has succeeded by taking some of the mystery out of preceptorship and helped participants to recognise the talent for facilitation they already display in practice and the collegial support readily to hand. Emancipatory concepts and processes that were used to guide the project focus on the development of individual nurses and midwives, and the cultures and contexts in which they work, with transformative action embedded in the outcomes (Manley et al, 2008). In the workshop participants are challenged to critique their own and the team's ability to provide a context in which learners can thrive. Positive program outcomes included change for participants that has had a positive influence on the development of a learning culture within our organisation. Not only has nursing in the hospital provided the requested increase in the number of placements for undergraduates, they have been able to demonstrate a consistently high standard in the quality of the clinical placements taken up by undergraduates (Courtney-Pratt et al 2011).

CONCLUSION

Practice Development has a central interest in people, culture and practice rather than systems and processes. Clinicians' participation in the preceptor program has led to changes in nurses' and midwives' knowledge that will further enable them to support learners within the organisation (Manley et al 2008). There is evidence of an interconnectedness between the development of knowledge and skills of the nurses and midwives and the enabling strategies that are utilised in the delivery of the program. Once again, these features of the program are also features of a Practice Development approach.

An interactive workshop based program was demonstrated to provide the necessary support for nurses and midwives to undertake the role of preceptor. The nature of the workshop enabled nurses and midwives to recognise the skills and knowledge that were inherent to their current practice, to share this with fellow attendees, and to build on their confidence to fulfil the role. As such it empowered them to take responsibility and credit for the supervision and growth of students, beginning practitioners and new staff, building on capacity to support the next generation of nurses and midwives at the study site.

ACKNOWLEDGEMENT

The authors would like to acknowledge the valued contribution Alison Evans made to the study design during her appointment to the Practice Development Unit-Nursing and Midwifery.

REFERENCES

Allen, C. and Simpson, A. 2000. Peers and partners: working together to strengthen preceptorship in mental health nursing. Journal of Psychiatric & Mental Health Nursing, 7(6):505-514.

Beanland, C., Schneider, Z., LoBiondo-Wood, G. and Haber, G. 1999. Nursing Research: Methods, Critical Appraisal and Utilisation. Mosby Publishers: Sydney.

Bourbonnais, F. and Kerr, E. 2007. Preceptoring a student in the final clinical placement: reflections from nurses in a Canadian Hospital. Journal of Clinical Nursing, 16(8):1543-1549.

Charleston, R. and Happell, B. 2005. Attempting to accomplish connectedness within the preceptorship experience: The perceptions of mental health nurses. International Journal of Mental Health Nursing, 14(1):54-61.

Courtney-Pratt, H., FitzGerald, M., Ford, K., Marsden, K. and Marlow, A. 2011. Quality Clinical Placements for Undergraduate Nursing Students: A cross sectional survey of undergraduates and supervising nurses. Journal of Advanced Nursing, published online at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2011.05851.x/abstract doi:10.1111/j.1365-2648.2011.05851.x

Dibert, C. and Goldenberg, D. 1995. Preceptors' perceptions of benefits, rewards, supports and commitment to the preceptor role. Journal of Advanced Nursing, 21(26) 1144-1151.

Fox, R., Henderson, A. and Malko-Nyhan, K. 2006. A comparison of preceptor and preceptee's perceptions of how the preceptor's role is operationalized. Journal of Clinical Nursing, 15(3):361-364.

Gibson, S. and Hauri, C. 2000. The Pleasure of Your Company: Attitudes and Opinions of Preceptors Toward Nurse Practitioner Preceptees. Journal of the American Academy of Nurse Practitioners, 12(9): 360-363.

Hallin, K. and Danielson, E. 2009. Being a personal preceptor for nursing students: Registered Nurses' experiences before and after introduction of a preceptor model. Journal of Advanced Nursing, 65(1): 161-174.

Health Workforce Australia. 2010. Clinical Supervisor Support Program--Discussion Paper, July 2010.

Heffernan, C., Heffernan, E., Brosnan, M. and Brown, G. 2009. Evaluating a preceptorship programme in South West Ireland: perceptions of preceptors and undergraduate students. Journal of Nursing Management, 17(5): 539-549.

Lather, P. 1991. Getting Smart: Feminist Research and Pedagogy with/in the Postmodern. Routledge: New York.

Manley, K., McCormack, B. and Wilson, V. 2008. Introduction, in K. Manley, B. McCormack and V. Wilson (eds). International Practice Development in Nursing and Healthcare. Blackwell Publishing: Oxford, 1-16.

McCormack, B., Manley, K. and Garbett, R. 2004. A Clearer Vision of Practice Development? Practice Development in Nursing. Blackwell Publishing: Oxford.

Mills, J., Francis, K. and Bonner, A. 2005. Mentoring, clinical supervision and preceptoring: clarifying the conceptual definitions for Australian rural nurses. A review of the literature. Rural and remote health, 5(3):410. Retrieved from: http://www.rrh.org.au/articles/subviewnew.asp?articleid=410 (accessed 21.05.2011).

Myall, M., Levett-Jones, T. and Lathlean, J. 2008. Mentorship in contemporary practice: the experiences of nursing students and practice mentors. Journal Of Clinical Nursing, 17(14):1834-1842.

Ohrling, K. and Hallberg, I. 2001. The meaning of preceptorship: nurses' lived experience of being a preceptor. Journal of Advanced Nursing, 33(4): 530-540.

Streiner, D.L. and Norman, G. R. 2008. Health Measurement Scales: a practical guide to their development and use. Fourth Edition. Oxford University Press, Oxford.

Usher, K., Nolan, C., Reser, P., Owens, J. and Tollefson, J. 1999. An exploration of the preceptor role: preceptors' perceptions of benefits, rewards, supports and commitment to the preceptor role. Journal of Advanced Nursing, 29(2):506-514.

Karen Ford RN PhD

ADON Research and Practice Development

Practice Development Unit-Nursing and Midwifery

Royal Hobart Hospital, School of Nursing and Midwifery

University of Tasmania

Email: karen.ford@dhhs.tas.gov.au

Helen Courtney-Pratt RN BN (Hons), PhD

Senior Lecturer School of Nursing and Midwifery

University of Newcastle

Email: helen.courtney-pratt@newcastle.edu.au

Mary Fitzgerald RN PhD

Professor of Nursing

School of Nursing, Midwifery and Indigenous Health

Charles Sturt University

Email: mafitzgerald@csu.edu.au
Table 1: Statement from pre and post program evaluation

1   My ability to use the Australian Nursing and Midwifery
    Council National Competency Standards for the Registered and
    Enrolled Nurse in practice is *

2   My ability to apply the Scope of Practice and Decision
    Making Framework to practice is *

3   My understanding of the role of a preceptor is *

4   My knowledge of the requirements of my role as a preceptor
    in relation to the structure of a range of nursing programs is *

5   My understanding of the principles of competency based
    assessment is *

6   My ability to use the Australian Nursing and Midwifery
    Council National Competency Standards for the Registered and
    Enrolled Nurse as a framework for assessment is *

* minimal to high using a five point Likert scale

Table 2: Demographics

N                                    93

No (%) Female                   87 (94)
No (%) Male                       5 (5)
Age group No (%)
  20-30                         35 (38)
  30-40                         15 (16)
  40-50                         31 (33)
  50-60                         12 (13)
Highest Qualification
  Hospital Qualification        17 (18)
  Degree                        48 (52)
  Graduate Certificate          11 (12)
  Graduate Diploma              15 (16)
  Masters                         1 (1)
Experience
  0 to 5 years                  38 (41)
  6-10 years                    11 (12)
  More than 10 years            44 (47)
Previous Preceptor Education
  Yes                           33 (35)
  No                            59 (63)

Table 3: Analysis Hopes, Fears and Expectations

                  Category        Examples from pre-workshop data

Hopes for the     Supervising     Improve confidence in dealing
acquisition of    people          with students.
Confidence and                    I want to be able to apply my
Ability                           learning effectively in the
                                  workplace.
                                  Successfully assist new staff
                                  and hope they wish to work on a
                                  long term basis in our
                                  specialised area.

                  Knowledge and   I will learn skills to pass on
                  understanding   knowledge and work effectively.
                  of the role     Do you have anything on scope of
                                  practice and curriculum etc.
                                  Improve knowledge of the
                                  assessment process
                  Facilitation    Understanding of precepting ...
                  skills          Learn some new techniques.
                                  Creating positive experiences ...

                  Reputation      ... this is something I will be
                                  good at I will be remembered as
                                  a positive mentor.

Fears that ...    Learning in     Jargon, buzz words.
it is too much.   workshop        Bamboozled by the theory of
                                  precepting.
                                  Bad acting in role play.

                  Workload        Having to deal with lots of
                                  students at once.
                                  More work than expected.

                  Failure         I feel inadequate at teaching
                                  I will learn that I have been
                                  a bad facilitator in the past.
                                  Undermined or not supported or
                                  respected by some peers.

Expectations      Cover           How to precept a difficult
that the                          personality
workshop                          ... dealing with difficulties
will ...                          relating to Preceptorship.
                                  ... know the paper work.
                                  How to access/perform [use]
                                  competencies.

                  Provide a       Relaxed learning environment, non
                  learning        judgemental and productive.
                  environment     Interactive day.
                                  Enjoy the day.

                  Enable          Be able to give feedback.
                                  Understand my role as a
                                  preceptor. To be a preceptor who
                                  I would like to have.

                  Category        Examples from post-workshop data

Hopes for the     Supervising     Gained knowledge in communication
acquisition of    people          techniques . problem solving and
Confidence and                    fundamentally being able to
Ability                           provide best outcomes for
                                  patients.

                  Knowledge and   Better understanding of how to
                  understanding   teach and help people learn.
                  of the role     Going through the competencies
                                  was really was really valid and
                                  helpful.
                                  I feel that I have a good overall
                                  picture of what's required.

                  Facilitation    Gained knowledge about preceptor
                  skills          relationship.
                                  I discovered I had more knowledge
                                  and skills as a preceptor than
                                  I thought and have gained more.

                  Reputation      I can do this!

Fears that ...    Learning in     ... I liked the interactive
it is too much.   workshop        nature of the day.

                  Workload        ... more confident, definitely
                                  more accepting of new students/
                                  grads not so intimidated.

                  Failure         Had more confidence and
                                  competence than [I] thought.
                                  More confident in being able
                                  to be a competent preceptor.

Expectations      Cover           Some good strategies for issues
that the                          were highlighted.
workshop                          I have learnt more avenues to
will ...                          seek help for difficult student.
                                  Gained knowledge in communication
                                  techniques, preceptor relationship,
                                  problem solving and fundamentally
                                  being able to provide best/safest
                                  outcomes for patients

                  Provide a       Workshop generated very valuable
                  learning        discussion about preceptorship.
                  environment     Supportive and inclusive
                                  environment.

                  Enable          Comfortable to give feedback.
                                  I feel I have a good overall
                                  picture of what is required.

Table 4: Paired samples t-test

                            Paired Differences

                                      Std.         Std.
                            Mean    Deviation   Error Mean

Pair 1   Pre_Q1 - Post Q1   -.602     .809         .084
Pair 2   Pre_Q2 - Post Q2   -.796     .891         .092
Pair 3   Pre_Q3 - Post Q3   -.903     .781         .081
Pair 4   Pre_Q4 - Post Q4   -.946     .771         .080
Pair 5   Pre_Q5 - Post Q5   -.839     .784         .081
Pair 6   Pre_Q6 - Post Q6   -.828     .996         .103

         Paired Differences

         95% Confidence Interval of
         the Difference

                                            Sig.
         Lower    Upper      t      df   (2-tailed)

Pair 1   -.769    -.435   -7.174    92      .000
Pair 2   -.979    -.612   -8.607    92      .000
Pair 3   -1.064   -.742   -11.152   92      .000
Pair 4   -1.105   -.787   -11.831   92      .000
Pair 5   -1.000   -.677   -10.314   92      .000
Pair 6   -1.033   -.623   -8.017    92      .000

Table 5: Pre and post evaluation mean, SD and error
(n=93 on all tests)

                   Mean   Std deviation   Std error mean

Statement   Pre    Post   Pre      Post    Pre      Post

1           3.16   3.76   .784     .682    .081     .071
2           3.14   3.94   .788     .719    .082     .075
3           3.42   4.32   .798     .645    .083     .067
4           3.04   3.99   .751     .617    .078     .064
5           3.06   3.90   .805     .627    .083     .065
6           3.03   3.86   .814     .760    .084     .079
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Title Annotation:Research Paper
Author:Ford, Karen; Courtney-Pratt, Helen; Fitzgerald, Mary
Publication:Australian Journal of Advanced Nursing
Article Type:Report
Geographic Code:8AUST
Date:Mar 1, 2013
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