The main purpose of Québec's order of nurses (Ordre des Infirmières et Infirmiers du Québec [OIIQ]) is to ensure the protection of the public by controlling the nursing practice of its members (Gouvernement du Québec, 2018). In 2011, the OIIQ established a professional requirement for continuing education (CE), making it an important professional responsibility as well as an ethical duty (OIIQ, 2011a). However, CE must be accessible and relevant to nurses throughout their career to contribute to the updating and development of all the specific knowledge and skills required for their respective professional practice (OIIQ, 2011b).
According to the OIIQ, critical care nurses work in emergency and intensive care units (OIIQ, 2016). Although CE is essential to all nurses, critical care practice-specific CE is a key element in hospitals as critical care nurses work in units featuring fast, numerous, and diversified medical and technological advances (OIIQ, 1996), and require specialized knowledge and advanced skills (Association des infirmières et infirmiers en soins intensifs du Canada, 2009). However, besides the general challenges related to CE (e.g., the cost of CE activities and the time required to attend CE activities), critical care nurses in remote areas face several additional challenges. For instance, access to relevant CE is compromised by their geographical isolation and the general nature of the care given in remote areas, which differs from the specialized care given in urban centers (Anderson & Kimber, 1991; Fairchild et al., 2013; Gaul & Croker, 1998).
Observations in care settings suggest that the CE needs of critical care nurses in Abitibi-Témiscamingue, a remote resource region in the province of Québec, are not being met because of the poor accessibility and relevance of the offered CE activities. In fact, in 2015, with respect to the rate of conformity to the OIIQ's professional requirement on CE, four of the province's six remote resource regions scored below the provincial average (81.6%): Abitibi-Témiscamingue (78.3%), Bas-St-Laurent (81.5%), Côte-Nord (79.1%), and Gaspésie-Îles-de-la-Madeleine (76.2%) (OIIQ, 2016). Although a number of studies elsewhere in the world (Australia, England, and the United States) have explored the CE needs of critical care nurses in remote areas (Casey et al., 2008; Chaboyer et al., 1997; Field, 2002; Gaul & Croker, 1998; Kidd et al., 2012; Paulson, 1996; Wolf & Delao, 2013), no previous Canadian study has addressed this topic. Thus, it was important to collect data about the specific CE needs of critical care nurses in these remote areas.
The overall aim of this study was to investigate the needs, opinions, and beliefs of critical care nurses working in remote resource regions in the province of Québec regarding CE. This study aimed to 1) evaluate critical care nurses' satisfaction regarding CE; 2) identify facilitators and barriers to their participation in CE activities; 3) describe their CE activities during the past year; 4) determine their preferences in terms of delivery modalities, topics, and organization of CE activities; and 5) describe their opinions and beliefs regarding continuing professional development (CPD) as measured by the Questionnaire of Professional Development of Nurses (Q-PDN) (Brekelmans et al., 2015).
Study Population and Design
A web-based cross-sectional study was conducted among a convenience sample of nurses who were members of the OIIQ between May and June 2018. Approval of the study was obtained from the Institutional Ethical Review Board of the University of Québec in Abitibi-Témiscamingue and the OIIQ. The OIIQ provided the email addresses of nurses meeting the following criteria: 1) the nurses had provided general authorization to the OIIQ to be contacted for research purposes; 2) the nurses worked in one of the six remote resource regions of the province as defined by the provincial revenue agency (Revenu Québec, 2018): Abitibi-Témiscamingue, Bas-St-Laurent, Côte-Nord, Gaspésie-Îlesde-la-Madeleine, Nord-du-Québec, and Saguenay-Lac-St-Jean; 3) nurses were listed by the professional order as potentially working in critical care settings: physical health and care to specific clienteles, critical care, or several fields of practice. This last criterion enabled the survey to reach a wide range of nurses potentially working in critical care settings. In addition, email invitations also were sent through Québec critical care nurses associations, the Québec Emergency Nurses Association (AIIUQ), and the Québec Intensive Care Nurses Regroupement (RIISIQ).
The email invitation included the questionnaire link that redirected potential participants to an introduction page detailing the objectives and selection criteria of the study. Nurses then were asked to provide informed consent for participation and to complete an anonymous French-language self-administered web-based questionnaire using the survey tool SurveyMonkey Gold®. To help increase the response rate, an email reminder was sent within 15 days (Deutskens et al., 2004). However, for ethical reasons (the research team did not have access to the contact information of AIIUQ and RIISIQ members), this reminder was only sent to nurses from the OIIQ contact list, and a 45-day response deadline was set (Edwards et al., 2009).
Questionnaire Development and Measures
The web-based questionnaire included items specially formulated for the purposes of this study and items from the validated Q-PDN data collection instrument. The first part of the web-based questionnaire included items to determine participants' satisfaction regarding CE (0 to 10 numeric rating scales), the facilitators and barriers to their participation in CE activities (5-point Likert scales), the quantity and nature of their CE activities in the past year (open-ended and semi-closed questions), and their preferences in terms of CE delivery modalities, topics, and organization (closed-ended questions). This section of the questionnaire was pretested between March and April 2018 with a sample of six nurses who were not part of the targeted population. Such testing then was reviewed by the research team (one expert in the development and validation of clinical tools and web-based questionnaires, one expert in critical care nursing, and one research student) to ensure appropriate clarity and length of completion. Only a few items of the questionnaire were identified as somewhat ambiguous by the participants during pretesting, and the research team made the appropriate changes. This section of the questionnaire took approximately 12 minutes to complete.
The validated Q-PDN data collection instrument was used to measure the opinions and beliefs of participants regarding CPD. This instrument took approximately 20 minutes to complete (Brekelmans et al., 2016). The Q-PDN is a 54-item, self-administered, instrument that measures four constructs, each divided into a number of factors:
The “motives” of the nurses to seek CPD, which include three factors (personal and professional development, requirements, and career opportunities—12 items).
The “conditions” considered necessary by the nurses for CPD, which include two factors (nonmaterial conditions and material conditions—12 items).
The “importance” granted by the nurses to CPD, which involves three factors (participation in research, clinical practice development, and participation in organizational development—15 items).
The actual “CPD activities undertaken” by the nurses, which are divided into the same three factors and 15 items as the “importance” construct (Brekelmans et al., 2015).
All items were measured using a five-point Likert scale ranging from “mainly disagree” to “mainly agree,” “not important at all” to “very important,” and “never to very often.” Total scores for each of the Q-PDN subscales were obtained by calculating the average of the items representing the 11 above-mentioned factors (subscales). Total scores ranged from 1 to 5 (Brekelmans et al., 2015, 2016). A French Canadian cross-cultural adaptation of this instrument was developed by the research team according to guidelines by Beaton et al. (2000) and used for this study.
Descriptive statistics (means, standard deviations, and frequency tables) were used to summarize participants' characteristics, as well as all questions assessing needs, opinions, and beliefs regarding CE. Bivariate analyses aimed at comparing CE variables across various subgroups (i.e., defined by region, field of practice, educational level, and years of experience) were conducted using chi-square tests, Student's t tests, Wilcoxon rank sum tests, and Kruskal-Wallis tests, depending on the type and distribution of CE variables. A Bonferroni correction was used when analyzing the Q-PDN subscale scores. Missing data were handled by pairwise deletion since the sample size did not allow for robust multivariate imputation. All statistical analyses were performed using SPSS® version 22.
The research team sent the email invitation to 1,644 nurses, members of the OIIQ. However, it was difficult to determine a response rate because many nurses not working in critical care settings also received the invitation, even though it was clear that the survey was only addressed to critical care nurses. Moreover, the email invitation was forwarded by critical care nurses associations to an unknown number of Québec nurses (these mailing lists were not shared with the research team for ethical reasons). The online questionnaire was accessed a total of 146 times. Among the total number of access requests, two participants did not proceed past the introduction and consent page, 44 viewed the questionnaire but did not provide any answers, and 22 were not eligible because they did not work in one of the six remote resource regions of the province of Québec. Thus, a total of 78 participants partially or fully completed the web-based questionnaire.
Participants' characteristics are presented in Table 1. Most of the participants were women (91.1%, 51 of 56) with a university degree (60.7%, 34 of 56) who had worked in critical care settings for 4 to 20 years (72.7%, 40 of 55). Nurses worked in the emergency department (46.2%, 24 of 52), the intensive care unit (15.4%, 8 of 52), or in both fields of practice (38.5%, 20 of 52). The questionnaire reached 56 participants from all six remote resource regions of the province of Québec: Abitibi-Témiscamingue (37.5%, n = 21), Bas-St-Laurent (21.4%, n = 12), Côte-Nord (7.1%, n = 4), Gaspésie-Îles-de-la-Madeleine (12.5%, n = 7), Saguenay-Lac-St-Jean (12.5%, n = 7), and Nord-du-Québec (8.9%, n = 5).
Characteristics of the Study Population
Satisfaction Regarding CE
Participants' satisfaction levels regarding actual CE activities during the past year, both general and critical care-specific CE, were measured using a scale of 0 to 10. Most reported a level of general satisfaction of 6 or higher (67.1%, 47 of 70). However, participants' satisfaction level regarding CE activities specific to their critical practice care was lower, with 49.3% (36 of 73) reporting a satisfaction level of 6 or higher.
Participants' satisfaction levels regarding the offering of CE activities in their region were measured using a 0 to 10 numeric rating scale. The region of Gaspésie-Îles-de-la-Madeleine had the lowest level satisfaction (M = 1.6; SD = 2.3) whereas the region of Nord-du-Québec reported the highest level of satisfaction (M = 6.2, SD = 3.1). However, no statistically significant differences (p < .05) were found when comparing satisfaction levels among all of the regions. In fact, a majority of participants in all of the regions reported a satisfaction level of 5 or lower (78.1%, 57 of 73).
Facilitators and Barriers of CE
Table 2 shows the five most common facilitators and barriers to participation in CE activities. There was a statistically significant difference (p < .05) between regions regarding access to internet. In the region of Nord-du-Québec, compared with all other regions, significantly more participants reported access to the internet (p = .019) as a barrier to participation in CE activities. However, overall, only a few participants identified this barrier (5 of 40).
Five Most Common Facilitators and Barriers to Participation in CE Activities
Moreover, other factors were identified as sometimes facilitating and sometimes as constraining: relevance of CE activities (40.9%, 27 of 66); personal disposition to learn (39.4%, 26 of 66), and delivery modalities of CE activities (36.4%, 24 of 66). In turn, the evaluation of CE activities and the choice of the instructors were factors identified as neither facilitating nor constraining participation in CE activities.
Actual and Desired CE Activities
During the past year, the majority of participants had complied with the OIIQ's professional requirement to complete a minimum of 20 hours of CE activities per year (80.5%, 62 of 77); at least 7 hours of CE activities must be accredited (i.e., must have been developed by an organization authorized to emit CE certifications or credits/units [OIIQ, 2011a]) (90.4%, 66 of 73). However, more than half of the participants (65.4%, 51 of 78) reported that less than 50% of their CE activities from the past year were related to their practice in critical care.
Figures 1 and 2 compare the actual versus desired delivery modalities and topics of participants' CE activities during the past year. No statistically significant differences (p < .05) were found between regions regarding desired delivery modalities. However, there were statistically significant differences (p < .05) between fields of practice regarding certain desired CE topics. Pediatric Advanced Life Support (PALS) (p =.026), Trauma Nursing Core Course (TNCC) (p = .009), and Canadian Triage and Acuity Scale (CTAS) (p = .003) were preferred by emergency nurses and those working in both units.
Comparison of actual and desired delivery modalities of continuing education activities. (Note. Participants could choose more than one response. Proportion of missing data across presented variables ranged between 6.4% and 20.5%.)
Comparison of actual and desired topics of continuing education activities. (Note. Participants could choose more than one response. Proportion of missing data across presented variables ranged between 14.1% and 23.1%.)
Preferences Regarding the Organization of CE Activities
Results related to preferences regarding the organization of CE activities showed the preferred times for nurses to access CE activities were during their work day (60.7%, 37 of 61) or on their days off (51.7%, 31 of 60) rather than before (38.3%, 23 of 60) or after (30%, 18 of 60) their work day. Moreover, the participatory approach (90.3%, 56 of 62) and lectures (77.4%, 48 of 62) were preferred over clinical supervision (67.2%, 41 of 61) and reflective practice (57.4%, 35 of 61). In addition, preferences for learning assessment (66.1%, 39 of 59) and CE activities evaluation (70.5%, [43 of 61]) were divided. Short duration training (≤8 hours) (100%) and activities that granted certification (100%) or CE credits/units (96.8%, 60 of 62) were desired by almost all of the participants.
Opinions and Beliefs About CPD
Table 3 presents Q-PDN subscale scores. The table reflects the participants' opinions and beliefs regarding their motives for CPD, the conditions they considered necessary to pursue CPD, the importance they granted to CPD activities, and the CPD activities they had actually undertaken. The greatest CPD motive was personal and professional development (M = 4.6, SD = 0.5). Clinical practice was considered the most important CPD activity (M = 4.1, SD = 0.6) and was also the most often undertaken CPD activity (M = 3.7, SD = 0.6). In addition, material conditions (M = 3.8; SD = 0.8) were considered more necessary than intangible conditions for the pursuit of CPD activities (M = 3.3; SD = 0.7). Moreover, importance given to participation in research (M = 2.9; SD = 0.7), actual participation in research (M = 2.1; SD = 0.4), and actual participation in organization development (M = 2.1; SD = 0.6) received the lowest scores. After a Bonferroni correction was applied (p < .005), no statistically significant differences were found when comparing Q-PDN subscale scores between groups based on experience in nursing (≤10 years and ≥11 years) and educational level (below a bachelor's degree and equal or above a bachelor's degree).
Opinions and Beliefs Regarding Continuing Professional Development
The aim of this study was to investigate the needs, opinions, and beliefs of critical care nurses in the remote resource regions of the province of Québec regarding CE. To date, no study of this kind has been conducted in Canada. In line with the recommendations of the public health organization of the province of Québec (Institut national de santé publique du Québec [INSPQ], 2008) and given the recent major health care system reform (Law 10) and the persistent shortage of nursing staff that forces more and more novice nurses into critical care settings (AQESSS, 2006; OIIQ, 2007), it was timely to proceed with this study and collect data about specific CE needs, opinions, and beliefs of critical care nurses practicing in these remote areas.
Summary of Findings
The findings of this study suggest the CE needs of critical care nurses in the remote resource regions of the province of Québec are not being met. This issue is highlighted by their low satisfaction levels regarding the CE activities offered in their region and the proportion of CE activities specific to their critical care practice. These findings are consistent with a recent literature review by Hendrickx and Winters (2017) about access to CE for critical care nurses in rural or remote settings. Their review found that critical care nurses' access to CE in rural or remote settings was difficult due to geographic isolation and perceived lack of applicable topics. Despite the relatively small sample size of the study, the findings provide valuable insights into the CE needs, opinions, and beliefs of critical care nurses in remote areas of Québec.
Comparison With the Literature
The findings of this study bear a resemblance to those reported in the literature regarding barriers to CE participation, preferences regarding CE delivery modalities, and preferences regarding CE topics. First, in their studies conducted among American/Canadian and Australian rural and critical access emergency nurses, Wolf and Delao (2013) and Kidd et al. (2012) reported that distance, time, finances, and staffing were barriers to CE participation. Similarly, Hendrickx and Winters (2017) identified barriers related to work (e.g., lack of financial resources, inadequate staffing to cover absences, lack of time due to workload, and lack of relevant CE topics) and travel (e.g., geographic isolation, distance, and travel time). Second, in a needs assessment study conducted among nurse practitioners from Canada's rural and northern communities, Tilleczek et al. (2005) reported that although participants recognize the benefits of information technologies, they still prefer face-to-face CE activities over any other delivery modalities.
Third, in a recent literature review, Pavloff et al. (2017) identified the CE needs of Canadian, Australian, Swedish, and American rural and remote nurses related to comprehensive specialized nursing practice for direct patient care (e.g., pediatrics, geriatrics, mental health, neurology, cardiology, pneumology, pharmacology, and special devices), unanticipated events (e.g., trauma and triage), nondirect patient care (e.g., technology) and advanced specialty courses (e.g., PALS, TNCC, and CTAS). Similarly, Hendrickx and Winters (2017) identified advanced physical assessment, triage, emergency care, caring for the critically ill, caring for patients with traumatic injury, and high-level critical thinking as CE needs. Thus, the present study findings could be relevant for a wider population than the one of critical care nurses in the remote resource regions of the province of Québec.
This study builds on these findings by addressing gaps between actual and desired CE delivery modalities (e.g., simulation, digital device self-learning, and virtual community of practice) and topics (e.g., psychosocial aspects, organ and tissue donation, education to patients and families, and use of research in clinical practice). These findings could be relevant for critical care nurses in the remote resource regions of the province of Québec.
This study also appears to be the first to conduct a needs assessment among critical care nurses in remote areas using the Q-PDN data collection instrument. The Q-PDN has been used previously to assess the CPD opinions and beliefs of Dutch nurses and to detect differences between nurses from a non-Magnet® university hospital in the Netherlands and nurses from a Magnet® university hospital in the United States (Brekelmans et al., 2015, 2016). Overall, the present study's findings tend to be in line with those from the Netherlands. Unlike American nurses from Magnet® university hospitals, critical care nurses in the remote resource regions of the province of Québec require enhanced conditions to participate in CPD activities. In fact, in Magnet® hospitals, great importance is given to professional development, which according to the Magnet Model®, is one of the Forces of Magnetism (American Nurses Credentialing Center [ANCC], 2018). This suggests that Magnet® hospitals, given their positive impact on the professional development of nurses, could serve as models to change the governance structure of Québec health care.
Strengths and Limitations
This study has several strengths, including anonymity and the use of a validated instrument (Q-PDN) and a web-based questionnaire, which reduce the possibility of social desirability and information biases. The use of a web-based questionnaire in this study not only prevented data entry errors, but also allowed the recruitment of critical care nurses from all six remote resource regions of the province of Québec. However, ethical reasons made it difficult to calculate a response rate or to compare the characteristics of participants and nonparticipants as the complete contact list of OIIQ, AIIUQ, and RIISIQ members were not available. Nevertheless, the mean age (38.3 years) and the proportion of men (8.9%, 5 of 56) in this study sample are similar to that of the Québec nursing work-force (mean age of 41.5 years and 11.1% men) (OIIQ, 2018), thus reducing the possibility of a selection bias.
Among the remote resource regions of the province of Québec, Saguenay-Lac-St-Jean, Bas-St-Laurent, and Abitibi-Témiscamingue are those with the most nurses (OIIQ, 2018), which was reflected among the participants of this study. Participants' educational level (69.6%, 39 of 56 with a bachelor degree or higher), which is higher than the average of the Québec nursing workforce (43.9% with a bachelor degree or higher), and interest in the study topic (CE) are factors that may have influenced the decision of nurses to participate in the study, which in turn may have affected the results.
In addition, the possibility of a type II error in the analysis cannot be excluded considering the relatively small sample size reached with the convenience sample (n = 78). As 1,132 nurses were working in 2017 and 2018 in critical care settings in the remote resource regions of the province of Québec (OIIQ, 2018), this sample therefore may represent 6.9% of the target population. First, the difficulties encountered in recruiting participants for this study may be due to the low participation rate expected from health professional surveys (Cho et al., 2013) and the current challenging organizational and political contexts (health care system reform and mandatory overtime). Second, the use of intermediaries (OIIQ, AIIUQ, and RIISIQ) that may not have the current email addresses of their members also may have hindered the recruitment of participants. Third, the length of the questionnaire may have hindered participation, given that 44 individuals accessed the survey without providing any answers and that the proportion of missing data sometimes reached 33.3%. Special attention should be paid to recruitment and participation rates in future studies. Limiting intermediaries, recruiting from the field, and reducing questionnaire length or using other data collection methods could be solutions to improve recruitment and participation rates in future studies.
These findings raise strong concerns regarding the administrative, financial, and technological aspects of CE activities designed for critical care nurses in the remote resource regions of the province of Québec. They are essential to reach and persuade health care and education decision makers to invest time and resources in finding solutions that match the CE needs of critical care nurses in these remote areas. As the results suggest, these concerns can be addressed by extending CE activities offered in remote areas, increasing the proportion of critical care practice-specific CE activities, reimbursing CE expenses, and providing the necessary time to pursue CE activities. Thus, at the organizational level, hands-on policies regarding the reimbursement and release of nurses for CE activities could be inspired by the Magnet® Model (ANCC, 2018). At the regulatory level, the annual proportion of critical care-specific CE activities should be set. Finally, the findings of this study regarding CE-related facilitators/barriers, preferences, opinions, and beliefs could help education decision makers develop CE activities adapted to critical care nurses in these remote areas.
The results of this study suggest the CE needs of critical care nurses from the remote resource regions of the province of Québec are not being met due to a lack of accessibility and relevance of the CE activities offered. Despite the relatively small sample size of the study, these findings are consistent with those reported in the literature (Brekelmans et al., 2015, 2016; Hendrickx & Winters, 2017; Kidd et al., 2012; Pavloff et al., 2017; Tilleczek et al., 2005; Wolf & Delao, 2013) and provide valuable insights into the CE needs, opinions, and beliefs of critical care nurses in remote areas of Québec. The problem could be addressed by extending the offer of CE activities in their regions and increasing the proportion of CE activities specific to their critical care practice. Moreover, material conditions such as the reimbursement of CE expenses and release time should be provided to encourage CE. The critical care nurses and health care/education decision makers from the remote resource regions of the province of Québec must work together to make CE accessible and relevant. More research is needed to determine the extent of each stakeholder's (i.e., nurses, health care institutions, educational institutions, professional associations, and professional order) participation in CE and to determine how much and how often CE should be offered.
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Characteristics of the Study Population
|Age, y, mean ± SD||38.3 ± 1.2|
|Years in nursing|
| 0 to 3||2||3.6|
| 4 to 10||17||30.4|
| 11 to 20||24||42.9|
|Experience in critical care, y|
| 0 to 3||9||16.4|
| 4 to 10||19||34.5|
| 11 to 20||21||38.2|
|Field of practice|
| Intensive care||8||15.4|
| College (CÉGEP)||13||23.2|
| University certificate or diploma below bachelor level||4||7.1|
| Bachelor's degree||34||60.7|
| University certificate or diploma above bachelor level||4||7.1|
| Master's degree||1||1.8|
| Bedside nurse||46||82.1|
Five Most Common Facilitators and Barriers to Participation in CE Activitiesa
| Access to computer||40||60.6|
| Access to internet||40||60.6|
| Quality of CE activities organization||23||34.8|
| Information received about CE activities||20||30.8|
| Access to scientific literature||19||28.8|
| Working hours||45||68.2|
| Distance and travel||45||68.2|
| Time freed to attend CE activities||43||65.2|
| Costs of CE activities||38||57.6|
| Financial support||34||51.5|
Opinions and Beliefs Regarding Continuing Professional Development a
|Construct||Factors||Entire Sample, M ± SD||Experience in Nursing||p||Educational Level||p|
|≤ 10 y, M ± SD||≥ 11 y, M ± SD||Below Bachelor's Degree, M ± SD||Bachelor's Degree or Higher, M ± SD|
|Motives||Personal and professional development||4.6 ± 0.5||4.6 ± 0.5||4.6 ± 0.5||.579||4.5 ± 0.6||4.6 ± 0.4||.828|
|Requirements||3.1 ± 1.0||3.4 ± 1.1||3.0 ± 0.8||.129||3.4 ± 0.8||3.1 ± 1.0||.248|
|Career opportunities||3.8 ± 0.7||3.9 ± 0.6||3.7 ± 0.8||.576||3.6 ± 0.8||3.9 ± 0.7||.152|
|Conditions||Intangible conditions||3.3 ± 0.7||3.4 ± 0.6||3.2 ± 0.7||.301||3.2 ± 0.6||3.3 ± 0.7||.469|
|Material conditions||3.8 ± 0.8||3.9 ± 0.6||3.8 ± 0.7||.758||3.8 ± 0.6||3.8 ± 0.8||.916|
|Importance||Participation in research||2.9 ± 0.7||3.0 ±0.7||2.8 ± 0.7||.135||2.6 ± 0.5||3.0 ± 0.8||.048|
|Clinical practice development||4.1 ± 0.6||4.2 ± 0.5||4.0 ± 0.5||.309||3.9 ± 0.5||4.2 ± 0.6||.128|
|Participation in organization development||3.2 ± 0.8||3.0 ± 0.7||3.2 ± 0.8||.618||2.9 ± 0.5||3.3 ± 0.8||.046|
|Activities undertaken||Participation in research||2.1 ± 0.4||2.1 ± 0.5||2.1 ± 0.4||.906||2.0 ± 0.3||2.2 ± 0.5||.269|
|Clinical practice development||3.7 ± 0.6||3.7 ± 0.6||3.7 ± 0.6||.486||3.6 ± 0.6||3.8 ± 0.6||.674|
|Participation in organization development||2.1 ± 0.6||1.9 ± 0.3||2.2 ± 0.6||.123||2.0 ± 0.5||2.1 ± 0.6||.874|