Citation
Respiratory therapy validation examinations

Material Information

Title:
Respiratory therapy validation examinations a community college model
Creator:
Moody, Linda Elizabeth, 1941-
Publication Date:
Language:
English
Physical Description:
ix, 83 leaves : ; 28 cm.

Subjects

Subjects / Keywords:
Cognitive models ( jstor )
College students ( jstor )
Community colleges ( jstor )
Curriculum evaluation ( jstor )
Educational evaluation ( jstor )
Equivalency tests ( jstor )
Personnel evaluation ( jstor )
Psychodrama ( jstor )
Respiratory therapy ( jstor )
Simulations ( jstor )
Curriculum and Instruction thesis Ph. D
Dissertations, Academic -- Curriculum and Instruction -- UF
Respiratory therapy ( lcsh )
Respiratory therapy -- Employees ( lcsh )
City of Gainesville ( local )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis--University of Florida.
Bibliography:
Bibliography: leaves 66-70.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Linda Elizabeth Moody.

Record Information

Source Institution:
University of Florida
Rights Management:
This item is presumed in the public domain according to the terms of the Retrospective Dissertation Scanning (RDS) policy, which may be viewed at http://ufdc.ufl.edu/AA00007596/00001. The University of Florida George A. Smathers Libraries respect the intellectual property rights of others and do not claim any copyright interest in this item. Users of this work have responsibility for determining copyright status prior to reusing, publishing or reproducing this item for purposes other than what is allowed by fair use or other copyright exemptions. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder. The Smathers Libraries would like to learn more about this item and invite individuals or organizations to contact the RDS coordinator(ufdissertations@uflib.ufl.edu) with any additional information they can provide.
Resource Identifier:
025725184 ( ALEPH )
03231482 ( OCLC )

Downloads

This item has the following downloads:


Full Text










RESPIRATORY THERAPY VALIDATION EXAMINATIONS:
A COMMUNITY COLLEGE MODEL











By

LINDA ELIZABETH MOODY


A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY





UNIVERSITY OF FLORIDA


1977













ACKNOWLEDGMENTS


I am particularly indebted to Professor Margaret K.

Morgan who was mainly responsible for my involvement in this study and, as chairwoman of my committee, provided substantial support and encouragement. To the members of my committee, Professors James W. Hensel, Amanda S. Baker, Gordon D. Lawrence, and Carol E. Taylor, I am also deeply grateful.

Appreciation is due the following faculty members at

Santa Fe Community College for assisting me in implementing the testing models: Ronald H. Sanderson, Robert W. Cornelius, Carol B. Swewczyk, and David A. Desautels.

My special gratitude is extended to Professors Wilson H. Guertin and Ronald G. Marks for their advice regarding the research design and analysis and to Sue M. Legg and Arlene D. Barry for their reviews of the examinations and assistance with the item analysis.

I owe significant debts to Gloria J. Nunley, Chief of the Nursing Service at the Veterans Administration Hospital, Gainesville, Florida, whose assistance in arranging my leave of absence was vital to completing this study, to the members of the University of Florida Division of Pulmonary Medicine, headed by Dr. Alan J. Block, for sharing their knowledge of










pulmonary medicine and to my typist, Edna B. Larrick, for her unlimited patience and expertise.

My love and appreciation are extended to my husband,

Edwin H. Holmes, Jr., my parents, Mr. and Mrs. L. J. Moody, and my relatives and friends, whose valuable support and encouragement contributed significantly to the completion of this study.


iii













TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ......... ................... ii

LIST OF TABLES ......... ............. ....vi

ABSTRACT ............................. ..... vii

CHAPTER
I INTRODUCTION ... ..... ..... ........ ..1

The Problem Statement ..... ............ 2
Purpose of the Study ...... ........ ... 3
Background of the Study .... ............ 3
Definitions .. ................ 7
Assumptions, Limitations, and Delimitations 8

II A SYSTEMS APPROACH TO EVALUATION ... ....... 9

Underlying Concepts and Values of Validation
Examinations ......12
Multidimensional Approaches to Evaluation 15 Selection of Evaluation Approaches ....... ..20 The Cognitive Model .... ............. . 22
The Clinical Model ... ............. . 24

III INITIAL TESTING OF THE COGNITIVE MODEL . . . . 28

Sample Selection and Sample Studied ..... . 28 Hypotheses ..... ................... . . 30
Methodology ...... ................. 31
Item Analysis ... .............. 34
Data Presentation and Analyses .. ........ .. 38
Conclusions ...... ................. 53

IV EVALUATING THE CLINICAL MODEL .. ....... . 55

Recommendations for Future Research and
Utilization ...... ................ 59
Summary ....... ................... 63

BIBLIOGRAPHY ........ ..................... 66










TABLE OF CONTENTS (Continued)


APPENDIXES

A Santa Fe Community College-Credit by
Exam Policy . . . . . . . . . . . . . . .
B The Models-Obtaining Information ........
C RS-101 Introduction to Respiratory Therapy
RS-121 Medical Gas Therapy .. ...........
RS-122 Humidity Therapy ..........
RS-123 Intermittent Positive Pressure
Therapy . . . . . . . . . . . . .
RS-141 Respiratory Therapy Pharmacology
RS-151 Cardiopulmonary Resuscitation . ...
RS-250 Cardiopulmonary Anatomy and
Physiology ..... .............
D Descriptive Data of RTVE Scores ..........
Frequency Distribution of RTVE Scores . . ..

BIOGRAPHICAL SKETCH ................


Page


71 72 73
74 75

76 77 78


* 79
* 80
81













LIST OF TABLES


Table Page
1 Clinical Performance Areas and Evaluation
Mechanisms ....... .................. . 26

2 Distribution of Test Items ... ........... . 32

3 Descriptive Statistics of Examinees' Total
Scores on the RTVE ..... .............. . 35

4 Descriptive Data and Total Scores of Examinees
on the RTVE by Groups ... ........... . 39

5 Scattergram Depicting Correlation Between
FTGAT and RTVE Scores ... ............ . 40

6 Analysis of Group Performance on the Total
RTVE ........ ..................... . 42

7 Analysis of Group Performance on Section IIntroduction to Respiratory Therapy ..... . 43

8 Analysis of Group Performance on Section IIMedical Gas Therapy .... ............. . 44

9 Analysis of Group Performance on Section IIIHumidity Therapy ..... ............... . 45

10 Analysis of Group Performance on Section IVIntermittent Positive Pressure Breathing . . . 46

11 Analysis of Group Performance on Section VRespiratory Therapy Pharmacology ......... ..47

12 Analysis of Group Performance on Section VICardiopulmonary Resuscitation .. ........ 48

13 Analysis of Group Performance on Section VIICardiopulmonary Anatomy and Physiology . . . . 49

14 Courses Passed by Group Members .. ......... . 52









Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
RESPIRATORY THERAPY VALIDATION EXAMINATIONS:

A COMMUNITY COLLEGE MODEL

By

Linda Elizabeth Moody

March 1977

Chairman: Margaret K. Morgan
Major Department: Curriculum and Instruction

Formal testing procedures that can be employed to assess proficiency of health workers are long overdue. This study developed a prototype to validate the competency of respiratory therapy personnel who wish to receive academic credit for knowledge gained through experience. Projected manpower needs for respiratory therapy established the purpose of the study: to develop diagnostic testing procedures that could be used to (1) grant academic credit and advanced placement and (2) prescribe the subsequent coursework required of candidates who take the national respiratory therapy examination to become registered. The use of validation examinations (equivalency and proficiency examinations) will provide career opportunities for those personnel (70% of the total respiratory therapy work force) who might otherwise be disqualified from working within the field because they have not been registered.

A systems approach was used to develop validation examinations for seven courses offered in the first year of the respiratory therapy program at Santa Fe Community College, Gainesville, Florida. Objectives from the seven courses vii









formed the basis for the content of the examinations, to assure content validity. Two models were developed that comprised multidimensional approaches to evaluate problem-solving ability and interpersonal and manipulative skills-the cognitive model and the clinical model. The cognitive model was a three and one-half hour examination consisting of 210 multiple-choice items that tested for memory, discrimination, evaluation, and problem-solving skills. A candidate had to score satisfactorily on each section of the cognitive examination to qualify to take the clinical examination.

Nineteen subjects participated in the initial testing of

the cognitive model that compared performances of three groups: Group I (five sLdents who had completed the seven courses and had had respiratory therapy experience), Group II (eight students who had completed the seven courses but had had no respiratory therapy experience), and Group III (six respiratory therapy personnel with experience but no course work). Item analysis of the written validation examination revealed that 88% of the test items had adequate discrimination and difficulty indexes. The reliability of the 210-item, multiplechoice examination, using Kuder-Richardson's formula 20, was sufficiently high (.88); the examination possessed content validity. Twenty-six items were revised for use in subsequent testing; none of the test items was of such poor quality to require deletion.

Nonparametric analysis of variance, using the KruskalWallis procedure, revealed significant differences in performance among groups (p< .05) on the total examination and viii









four of the separate, course examinations. A high correlation (r= .8318) was found between scores on the Florida Twelfth Grade Achievement Test and the total respiratory therapy validation examination. Procedures were proposed for assisting applicants to improve their test-taking skills.

The clinical model comprised several evaluation approaches (clinical simulations, oral examinations, and role playing) that were designed to measure predefined interpersonal, psychomotor, and problem-solving skills. Role-playing examinations were videotaped for faculty review to obtain inter-rater reliability. Subsequent testing was advised with the clinical model to assess the reliability of the evaluation instruments used. Development of validation examinations for courses offered during the second year of the respiratory therapy program at Santa Fe Community College was recommended.

Both models may be employed for summative evaluation of

generic students in the respiratory therapy program. Students' achievement on the validation examinations may be later compared with their performance on the national registry examination to provide follow up and accountability. Use of the testing models in two-year respiratory therapy programs would not only make curricula more accessible to the work force but would increase the number of qualified respiratory therapists. The study carries implications for all educators concerned with upgrading health care delivery.













CHAPTER I


INTRODUCTION



More than 40,000 respiratory therapy personnel were

available in 1976 to fulfill national manpower needs. But of these 40,000 only 10,500 (26%) have been certified or registered to practice in the field of respiratory therapy (Occupational Outlook Handbook, 1976). A survey (Sanderson, 1976) revealed that Alachua and Bradford counties in Florida had 1,435 hospital beds and 92 respiratory therapy personnel. Only 6 of the 92 practicing respiratory therapists were registered (Sanderson, 1976).

National statistics revealed that more than 60% of

respiratory therapy personnel had inadequate education and training to prepare them to qualify for and pass national licensing or certifying examinations (Youtsey, 1975). Hospital-based training has been ineffective for preparing respiratory therapists for an occupation that demanded complex intellectual and psychomotor skills. Respiratory therapy has been the only allied health profession that has not required licensure or certification in order to practice within the field. McAleer (1975) expressed concern that many capable technicians would never have the opportunity to become









certified because one year of full-time schooling was inaccessible or impossible.

The American Association of Respiratory Therapy (AART) recognized the need for registration and certification in order to maintain standards of care; therefore, the AART will soon require all practicing respiratory therapy personnel to be registered or certified. Although many respiratory therapy programs have espoused the use of validation examinations, few, if any, have developed a flexible curriculum that provides formal evaluation procedures to grant advanced standing. The use of validation examinations would assist many qualified respiratory therapy personnel in obtaining the registration that will soon be required by the AART.


The Problem Statement


Diagnostic testing procedures were needed to evaluate previously acquired knowledge and experience of hospitaltrained respiratory therapy personnel so that (1) academic credit and advanced placement could be granted for extant skills, and (2) formal instruction and clinical experiences prescribed to qualify candidates to take the registration examination offered by the National Board of Respiratory Therapy (NBRT).










Purpose of the Study


The purpose of the study was to develop proficiency and

equivalency examinations (validation examinations) that would be used for granting advanced placement to informally trained respiratory therapy personnel applying to the Santa Fe Community College Respiratory Therapy Program.

The study was concerned with five major objectives:

1. Identification of types of examinations that are
appropriate for each respiratory therapy course
under study.

2. Development of cognitive examinations for the seven
respiratory therapy courses to be used for validation examination.
3. Initial testing of the cognitive examinations with
a group of students who have completed the seven
respiratory therapy courses and a group of respiratory therapy workers who have had no formal coursework. Data analysis including descriptive statistics and analysis of variance.

4. Proposal of methods of affective and psychomotor
examinations that may be used for validation examination of the courses under study.

5. Prescription of methods of evaluation and accountability for all advanced-placement students.


Background of the Study


Respiratory therapy, a relatively young occupation that emerged in the mid-1940s, grew out of rapid technological



Support for the study was received from a Staff Program and Development Grant funded by Santa Fe Community College, Gainesville, Florida, Project No. 122370.









advances in medicine and surgery that required skilled personnel who could work with respiratory ventilators (Whitacre, 1972). The need for hospital staff who could manage complex ventilatory care became acute. To counteract the shortage of skilled staff, most hospitals hired persons (many without previous medical education or experience) to be trained on the job by physicians.

Respiratory therapy personnel, formerly referred to as inhalation therapists, treat patients with cardiorespiratory problems. Treatment may range from giving assistance to persons with acute asthma to rendering emergency care in cases of drowning, heart failure, shock or other disorders that interfere with breathing. Respiratory therapy workers may be the first ones summoned during crises ; thus, the role requires a high level of responsibility and skill (Occupational Outlook Handbook, 1976).

The advent of complex mechanical ventilators in the 1950s created a new type of health care unit called "intensive care" that demanded specially trained physicians, nurses, and respiratory therapists. As clinical skills increased in number' and complexity, respiratory therapists needed a broader theoretical base in the sciences to provide an understanding of equipment and job functions charged to them.

During the ensuing years, hospital-based training proved to be an ineffective method for educating personnel to adequately perform the skills required of a registered









respiratory therapist (Youtsey, 1975). Physicians have been responsible for initiating curricular developments and training programs for respiratory therapists. The American Registry of Inhalation Therapy (ARIT) was founded in 1960 and with support from the American Medical Association (AMA) pilot examinations for registration began in 1961 (Whitacre, 1972).

Basically, three levels of workers have performed within the field of respiratory therapy: therapists, technicians, and assistants. Respiratory therapists have a certificate of graduation from an AMA-approved training program, sixty-two semester hours of college credit, and one year of clinical experience. Respiratory therapists would be eligible to apply for the registration examination sponsored by the National Board for Respiratory Therapy (NBRT). The registry examination has comprised two tests, a written and an oral.

Persons who have completed an AMA-approved technician training program and have one year of experience in respiratory therapy can apply to the NBRT for examination for the Certified Respiratory Therapy Technician(CRTT) credential. The CRTT examination has been less comprehensive than the registry examination and consisted of a written test only.

Requirements for respiratory therapy assistants have

been varied, according to requirements of the local hospital director; some training programs required a high school diploma or previous hospital work. Hospital-based training was made available for some respiratory assistants. No










licensure or certification has been required for respiratory therapy assistants (Occupational Outlook Handbook, 1976).

Since 1975, employment of respiratory therapy workers has been expected to increase faster than the average for all occupations. Respiratory therapy was one of the fastest growing allied health professions: Manpower needs will continue to spiral.

Owing to new uses for respiratory therapy, increased acceptance of its use, and the growth in health services in general, many specialists in respiratory therapy will be hired to release nurses and other personnel from respiratory work to return to their
primary duties. Those with advanced training in
respiratory therapy will be in demand to fill teaching and supervisory positions. (Occupational Outlook
Handbook,1976, p. 469)

Many respiratory therapists have favored providing ways for respiratory therapy assistants and technicians to move up the career ladder to help fulfill national manpower needs. Youtsey proposed

Mechanisms that deserve the most serious consideration
are proficiency and equivalency examinations for advanced standing in approved respiratory therapist programs. (1975, p. 1050)

As of 1976, no respiratory therapy programs in the United States have implemented a formal program for granting advanced placement, but several programs have expressed the intent to develop validation examinations in the near future (Wilson, 1976). The NBRT has strongly encouraged programs to employ equivalency examinations so that more personnel may become registered.










Projected manpower needs within the field of respiratory therapy justified development of mechanisms to increase career mobility for all personnel. The development and use of validation examinations may provide career advancement for many personnel who might otherwise be eventually disqualified from working within the field because they have not been certified or registered. Validation examinations may also provide a service to health care consumers by improving the quality of care received during hospitalization.

If the proposed validation examinations at Santa Fe Community College prove to be effective mechanisms for assisting persons to become registered respiratory therapists, then the testing models may be adapted for use throughout respiratory therapy programs in the United States.


Definitions


Advanced placement (standing) - the granting of academic
credit, for experience and knowledge gained informally,
to candidates who pass exemDtion (validation) examinations.

Proficiency examination - an evaluation method that tests
for competence derived from training and practice in clinical skills; it also tests for clinical aptitude
and problem-solving ability (Wilson, 1976).

Equivalency examination - an evaluation procedure that compares theoretical knowledge with that offered by the
formal program (Wilson, 1976).

Validation examination - evaluation approaches that consist
of a combined proficiency and equivalency examination.

Generic student - a student enrolled in the respiratory therapy program at Santa Fe Community College, who has not
been granted advanced placement.









Assumptions, Limitations, and Delimitations


A major assumption of this study was that valid and reliable methods could be developed to assess cognitive, affective, and psychomotor skills of respiratory therapists. Another assumption was that applicants who score as well as generic students on the validation examinations have attained equivalent knowledge as compared to students who have completed the respective coursework in the respiratory therapy program at Santa Fe Community College.

A major limitation of the study was the inclusion of only one testing session, while recognizing that several testing sessions with validation examinations would be required to produce cognitive and clinical evaluation models of acceptable validity and reliability.

Since the validation examinations were based on specific course objectives and the Respiratory Therapy Task Analysis (1975), the examinations were delimited for use at Santa Fe Community College but could be adapted for similar programs nationwide. Results from initial testing of the cognitive model were not generalizable beyond the samples studied.














CHAPTER II


A SYSTEMS APPROACH TO EVALUATION


A systematic approach to curriculum development will facilitate the development and,utilization of validation examinations. The process of curriculum planning is a dynamic one that includes data collection, prescription, treatment, and evaluation. Saylor and Alexander defined curriculum as "a plan for providing sets of learning opportunities to achieve broad goals and specific objectives for an identifiable population served by a single school center" (1974, p. 6). Since the primary purpose of the study was to develop evaluation procedures for granting advanced placement, the entire curriculum plan at Santa Fe Community College required appraisal.

Evaluation is an integral part of curriculum design and curriculum planning. Stufflebeam and other educators (1971, p. XXV) defined evaluation as "the process of delineating, obtaining, and providing useful information for judging decision alternatives." Evaluation encompasses but surpasses the meanings of the terms "test" and "measurement" (Mehrens and Lehmann, 1973).

Mehrens and Lehmann explained the attributes of evaluation:










1. provides knowledge concerning the students' entry
behaviors;
2. assists in setting, refining, and clarifying realistic goals for students;
3. determines the degree to which objectives have been
achieved;
4. assists in determining, evaluating, and refining
instructional techniques;
5. communicates goals of the teacher and increases
motivation;
6. provides feedback to students that identifies their
strengths and weaknesses; and,
7. aids in the administrative decisions of selection,
classification, and placement. (1973, p. 15)

Evaluation measures predefined characteristics or properties

of people and should not be confused with evaluating a person's worth. Evaluation attempts to quantify predefined

qualities. Therefore, educators must be aware of the inherent weaknesses in the evaluative process and make concerted

efforts to eliminate deficiencies. Defining educational

goals in behavioral terms is one way to make the evaluation

process more equitable.

Evaluation presumes prespecified goals or objectives.

The systems approach to curriculum design offers an orderly,

inclusive process for identifying goals and objectives.

A systems approach to curriculum design involves twelve

stages, according to Gagne and Briggs (1974, p. 213):

1. Analysis and identification of needs
2. Definition of goals and objectives
3. Identification of alternative ways to meet needs
4. Design of system components
5. Analysis of resources required, resources available,
and constraints
6. Action to remove or modify constraints
7. Selection and development of instructional materials
8. Design of student assessment procedures
9. Field testing-formative evaluation and teacher
training









10. Adjustments, revisions and further evaluation
11. Summative evaluation
12. Operational installation


Not all systems design theorists follow the outline

proposed by Gagne and Briggs but all support the idea that an ongoing, systematic effort is made to define learner needs, learner objectives, evaluate learner behavior, and revise objectives and instruction when indicated.

An effective way to design a curriculum is to work backwards from the outcomes it is expected to have. Educational goals are statements of the outcomes of education; they must be identified before instruction and evaluation can be intelligently designed (Gagne and Briggs, 1974).

Valid and reliable evaluation methods can be developed after the curriculum objectives for each course have been stated in behavioral terms and the three learning domains considered (cognitive, affective, and Psychomotor). Scannell and Tracy supported this approach:

Stating in advance explicit objectives for instruction
will improve the quality of evaluation by making it reflect more accurately the teacher's true instructional intentions. (1975, p. 28)

Controversy may be sparked when development of affective objectives is discussed. Critics argue that writing affective objectives in behavioral terms becomes a trivial task and masks the real learner behavior that is desired. Thus, some educators completely abandon the complex task of identifying values students should possess as a result of











instruction. Radocy (1974) asserted that quantification of affective behavior was not a problem of measurement theory, but a problem of human negotiation. If identified values are important for learners to possess, the evaluator must state what is acceptable evidence of a desired condition. Failure to consider the affective domain results in an instructional program that is often labeled "mechanistic" by students; this may be the reason systems design is thought to be less humanistic. However, the curriculum planner has the option of building in the humanistic elements in any design that is selected; this seems especially important to include in any health related program.

Before validation examinations are considered in any program, a sound educational curriculum is required. Appraisal of general program and specific course objectives at Santa Fe Community College revealed an educational readiness to undertake the development of validation examinations. Behavioral objectives from the seven courses under study and the Respiratory Therapy Task Analysis (1975) provided the structure, content, and formats for the validation examination.

Underlying Concepts and Values of Validation Examinations

Any program that adopts the use of validation examinations supports the belief that learning is not confined to the classroom but occurs through meaningful experiences that










involve learners actively; this commitment was shared by the respiratory therapy faculty at Santa Fe Community College. Many persons, through personal experiences or work situations, develop attributes and competencies similar to those developed by students in academic programs. People deserve an opportunity to gain academic credit for their expertise without repeating educational experiences designed to develop skills when those skills are already possessed.

The use of validation examinations was founded upon the American educational belief that people should be encouraged and assisted to approach their potential. Wilson (1976) defined equivalency as

. . . the comprehensive evaluation of knowledge and
skill competencies and the emotional attributes developed through alternate experience to determine if
those thus gained are equivalent to the competencies and attributes developed through the formal program
of the educational institution. (p. 232)


Desired learner attributes and behaviors must be identified for each course within the curriculum prior to the development of validation examinations. Otherwise, no standards exist with which to compare the expertise submitted by the candidate.

The concept of equivalency evaluation or validation examination implies that competencies and attributes of like value and significance will be honored. Validation examination is a summative type evaluation that measures progress achieved over a longer period of time and supplies information about









subsequent instruction and learning needed by the student (Wilson, 1976). The validation process is diagnostic and prescriptive; it reveals how well the candidate meets the qualifications of a practitioner within the selected field.

Faculty who adopt validation examinations must show that generic students in their program can pass the examinations; it would be unfair to judge applicants by standards that generic students were not able to achieve.

A flexible curriculum that allows entry at most course levels is essential if validation examinations are implemented. To require applicants to take courses unnecessarily would decrease motivation and defeat the purpose of the program. Enthusiastic proponents of exemption examinations express the idea that all students should be assessed for levels of knowledge and then placed in appropriate courses. National use of the College-Level Examination Program (CLEP) is an example of educational efforts to consider individual abilities and experiences.

Development of validation examinations for use at Santa Fe Community College will serve the express purpose of providing a mechanism for respiratory therapy personnel to qualify to take the NBRT registration examination. Thus, it will not only offer career opportunities but provide a service to health care consumers.

Faculty must be able to express their ideas and beliefs freely to one another regarding validation examinations.










Consensus must be reached as to how the examinations will be developed and implemented and what kind of grading system will be used for candidates who pass the validation examinations.

Wilson (1974) surveyed 150 health practitioner programs in the United States and reported that 28 offered some type of informal equivalency testing. Wilson also found that most faculty viewed equivalency testing as traditional credit by examination. If faculty have this misconception, they may be reluctant to use validation examinations from fear that many students will be able to exempt all of their courses.

Faculty of health programs, who accept the use of validation examinations, must be wholly committed to the development of capable practitioners who possess the minimum basic competencies and attributes required for proficient practice; the validation examinations must be designed to test for basic competencies and attributes. Thus, more than one testing approach is required.



Multidimensional Approaches to Evaluation


The concepts underlying the use of validation examinations demanded that more than one testing approach be used to assess the cognitive, affective, and psychomotor skills of candidates applying for advanced standing to the respiratory therapy program at Santa Fe Community College.









Prior to planning evaluation approaches, an analysis of objectives for each course under study should be undertaken to determine what types of skills the learner is to perform: manual, verbal, memory, discrimination, or evaluation. The next step will involve identification of appropriate evaluative procedures for the respective skills.

Validation examination may include measurement procedures that have not been used extensively in academic programs. Creative and innovative approaches need to be explored, especially in the realm of clinical evaluation. Wilson (1976) suggested that media-supported evaluation and simulations be developed for evaluating competencies.

Only recently have simulations been seriously considered in academic programs. However, the use of simulations dates back to ancient times. Chess is the oldest form of war game and war games are the oldest type of simulations (Tansey, 1971). In the ideal simulation, the participant assimilates the information or material available to him in order that he may reach the goal set for him. Simulation makes it necessary to make sure of the facts, to collect, evaluate, and analyze the information. Then, there is an obligation to see the whole of the problem, or to diagnose the situation as it appears. Reflection, interpretation, and discussion are needed to crystallize the simulation (Tansey, 1971).

Simulation has many possibilities for use in evaluation of people in the health field because it is a useful device









for testing decision-making skills. Simulations can examine the large and complex pattern of human relationships and abstract portions that need investigation or that are considered important (Tansey, 1971, p. 29).

Taylor and Walford cited the primary objectives of simulation:

1. presenting a simplified abstraction of the bare
essentials to a situation free from trivia and
irrelevance;
2. concentrating on making explicit, essential relationships and the fundamental interplay between
key roles;
3. unfolding time at a quicker rate than normal so
that the implications of action in a dynamic situation can be clearly and repeatedly felt;
4. allowing students to "sit in the hot seat" and
feel the direct impact of the consequences of
decision making; and,
5. offering opportunities for collaborative learning
on self-directed lines. (Taylor and Walford,
1972, pp. 48-49)


A major type of simulation is role playing, which is

the simplest form, in that it has the least formal structure. Role playing relies on the spontaneous interaction of participants when placed in a hypothetical situation. Role playing was originally used in the 1930s as a means to study the psychological behavior of small groups (Tansey, 1971).

During the 1940s, role playing was used in drama as a

liberating and self-educating activity for pupils in school; the influence of role playing had more affective than cognitive impact, particularly in the free-form situations in drama or English lessons. "Theatre-in-Education" projects










that were sponsored by local repertory theatres became popular in the 1950s and 1960s (Taylor and Walford).

In role playing, the players accept assigned identities and act or react appropriately. The essential core of the activity is understanding the situation of the other person(s) and responding in kind. The player is given the opportunity to experience what is at stake. The presumption is that through such participation players gain a greater understanding of their roles and relations (Taylor and Walford).

A requirement of role playing is that the players must be able to assume the assigned roles. A simulation is ineffective if the participant is detached from the activity because involvement is the element that makes role playing an effective instructional and evaluation method.

Role playing has been used to help students in the health professions gain empathy into the helper-client relationships. Crisis situations that cannot be employed or participated in by students in clinical settings can be simulated and roleplayed if the expectations are well defined for the players and the situation is designed to represent a real-life situation. Spontaneous reactions of the player or examinee may serve as a guide to self-understanding and represent how that person may have acted in the true situation; it may serve as an effective evaluation procedure.










Simulations provide a degree of stress for the players but whether it is equivalent to the stress produced by the real-life situation in a hospital setting continues to be moot.

The most frequently used simulation in the health professions is cardiopulmonary resuscitation: a procedure requiring high levels of cognitive, affective, and psychomotor skills that must be performed correctly, within a few seconds. A life-like mannequin was developed to provide feedback to the resuscitator, indicating whether the procedure was done correctly. The model has proved successful for teaching and evaluating this complex skill required of health personnel.

The use of videotape to record role playing or clinical simulations is useful for evaluation and instructional purposes. Players and teachers gain a better understanding of their behavior; they can analyze mistakes and successes to respond more appropriately.

Planning and development time, number of personnel

required, and cost are the primary disadvantages of using simulations and videotape equipment.

Tansey discussed the importance of designing the elements of the simulation:

The designer of the model must make certain value judgments. He must decide what are the essential
processes and what processes are secondary. In
other words he must obviously decide what has to be left out. His aim, at this stage, is to reduce the










complexity of a real life situation, to simplify it
in order that its essence may be studied beneficially.
His dilemma is that if he puts too much of the actual
situation in he may so complicate the simulation as to make it a poor vehicle for instruction. On the
other hand, if he leaves too much out he may produce
a model that does not accurately represent the system
he wishes to present. He must also be aware of the danger of personal interest and the tendency toward
bias and distortion. (pp. 7-8)


Perhaps the most important steps of planning a simulation are first identifying the behaviors that are to be exhibited, then providing the examinee with enough data and support to exhibit the desired behaviors.



Selection of Evaluation Approaches


The researcher met with the respiratory therapy faculty at Santa Fe Community College to discuss possible evaluation approaches. The following questions were presented to gain needed faculty commitments:

1. What objectives from each course will be tested?

2. To what kind of testing does each objective lend

itself?

3. What objectives do faculty expect all students to

perform at an acceptable level?

4. What types of affective, cognitive, and psychomotor

evaluations are presently used for each course?

5. How, where, and by whom will the examinations be

administered?










6. Should the examinations be administered on the

same day or separate days: a session for cognitive evaluation and one for clinical evaluation?

7. What types of audiovisual equipment, clinical

facilities, and respiratory therapy equipment are

available to use for clinical evaluation?

8. How will the validation program interface with the

credit-by-examination policy at Santa Fe Community

College?


Several planning and think-tank sessions with the respiratory therapy faculty provided answers to many of the proposed questions. Faculty agreed that, considering the types of skills that were to be evaluated, the resources, and time available, two evaluation models would be developed: the cognitive model and the clinical model. The models would include several evaluation approaches to accommodate the various cognitive and performance styles of candidates.

Enthusiastic administrative support was received from

Santa Fe Community College to assist in implementing the validation program; financial support was granted to applicants taking the validation examination. Students are usually required to pay $15 per course for credit by examination (Appendix A).

Objectives from each of the seven courses were reviewed and categorized into the cognitive model or the clinical










model for testing. The content of both models was determined by the theoretical knowledge required to practice respiratory therapy proficiently and the affective and psychomotor skills thatwere essential for all respiratory therapy students to perform after completing the seven courses under study (Appendix B).



The Cognitive Model


The Respiratory Therapy Task Analysis (1975) and objectives from the seven courses were used to prepare Tables of Specifications for each course (Appendix C). The specification tables were distributed to the four respiratory therapy faculty who rated the content-topics of each course. The mean weights assigned by the faculty raters were used in developing the test items and weights for each content area.

Mehrens and Lehmann (1973) discussed the importance of preparing Tables of Specifications:

The purpose . . is to define as clearly as possible the scope and emphasis of the test, and to relate the objectives to the content. The test must be a valid
measure of the pupil's knowledge, skills, and other
attributes that the teacher sought specifically to teach.
By ensuring that the test adequately covers the content and is directly related to the objectives, the teacher
has satisfied the most important criterion of the testcontent validity. (p. 181)

The next step was to decide what type of testing format to use in the cognitive model. Because of the nature of the objectives being tested and the length of the material to be covered, the multiple-choice format was selected.









If developed and used judiciously, the multiple-choice

format can be a valid and reliable evaluation test. The

format allows versatility for testing different skills:

recall, recognition, discrimination, evaluation, application, or reflection. Unfortunately, many evaluators devise

multiple-choice examinations that only test memory skills.

Mehrens and Lehmann (1973) discussed the major advantages

and limitations of multiple-choice examinations. The following advantages were cited:

1. Multiple-choice questions can measure factual
recall but also measure reasoning ability,
judgment, and problem-solving.
2. The tests can be scored quickly and accurately.
3. They are relatively efficient in terms of the
number of questions that can be asked in a prescribed time, and the space needed to present
the questions.
4. Compared to true-false items, multiple-choice
questions have a relatively small susceptibility
to score variations due to guessing.
5. Multiple-choice items provide diagnostic information and greater reliability than true-false items.
6. Students prefer multiple-choice items because they
are less ambiguous than true-false questions.
7. Of all the selection-type objective items, the
multiple-choice item is most free from response
sets. (p. 280)

Critics of multiple-choice examinations argue that the

testing format leads to the asking of trivial, ambiguous

questions. However, triviality and ambiguity are not inherent in the format but interjected by the item writer.


The recognized limitations of multiple-choice items

were as follows:










1. They are difficult to construct. Teachers cannot
always think of plausible sounding distracters.
2. There may be a tendency to write multiple-choice
items demanding only factual recall.
3. Multiple-choice items require the most time for
students to respond, especially when very fine
discriminations have to be made.
4. Test-wise students perform better than nontest-wise
students. (Mehrens and Lehmann, 1973, p. 281)


The final form of the examination consisted of 210

multiple-choice items. All examinees should be able to complete the examination in three and one-half hours, allowing 60 seconds response-time per item (Noll and Scannell, 1972). For all test items, four distracters were used. All of the responses were alphabetized or placed in ascending numerical order, to avoid biased placement of the correct responses.

The researcher directed efforts toward constructing

test items that measured the examinee's ability to discriminate, make judgments, solve problems, and evaluate. Except for information and facts that respiratory therapists needed to know, factual-type questions were avoided. The examination was reviewed by three judges for clarity, readability, and accuracy of correct responses and revised prior to the initial testing.

The Clinical Model

The researcher designed the clinical evaluation to

measure several skills: clinical application of knowledge, ability to assemble, operate, and maintain selected respiratory therapy apparatus, verbal expression, interpersonal skills, and problem-solving ability.










The Respiratory Therapy Task Analysis (1975) and objectives for the first-year level courses were reviewed for the purpose of selecting content and objectives representative of the skills that students were expected to demonstrate after completion of the seven courses.

The respiratory therapy faculty were presented with a set of skills for each of the seven courses and asked to designate the skills that were essentiaZ for respiratory therapists to know and perform correctly. Faculty were also asked to select the skills that the examinee must perform without error.

The clinical examination included various testing

formats: oral expression, role playing, and demonstration of psychomotor skills. Before the clinical evaluation could be finalized, several faculty planning sessions were held to accomplish the following tasks:

1. Identify specific learner behaviors that apply to

the testing situations for each course

2. Establish performance standards

3. Decide how each testing situation is to be implemented.

Irby and Dohner (1976) discussed the developmental phases of clinical performance assessment:










1. Development of the management plan, which includes
the rationale, goals, activities, and resources
needed.
2. Instrument development, involves defining tasks and
performance standards, as well as creating and
field testing instruments.
3. Implementation, which consists of tasks that make
the system operational: training faculty to objectively and reliably observe student performance and
provide effective feedback; establishing a routine data collection and analysis process; determining grading procedures; and, reporting the results of
student achievement. (p. 208)

The evaluation mechanisms were employed to assess clinical performance in four areas (Table 1).


Table 1


Clinical Performance Areas and


Performance Area


Knowledge


Technical Skills Interpersonal Skills Habits and Attitudes


Evaluation Mechanisms

Evaluation Mechanisms

Oral examinations Clinical simulations Observations

Clinical simulations Observations

Role playing* Observations

Role playing Clinical simulations Observations


From Clinical evaluation: Alternatives for health
related educators, by D.M. Irby and M.K. Morgan,
1974, p. 2. Copyrighted 1976 by Margaret K.
Morgan. Cited by permission.



All role-playing simulations were videotaped for review by faculty raters.










The clinical evaluation model consisted of an agenda of behavioral skills to use when testing for the six courses listed below:

RS 101 Introduction to Respiratory Therapy
RS 121 Medical Gas Therapy
RS 122 Humidity Therapy
RS 123 Intermittent Positive Pressure Breathing
RS 141 Respiratory Therapy Pharmacology
RS 151 Cardiopulmonary Resuscitation


RS 123 and RS 141 were combined into one examination

since the skills of both courses are performed concurrently in the hospital situation. Faculty examiners were oriented to the checklist of behaviors and equipment and personnel schedules that were developed for administering the clinical examination. The laboratory facilities at the Respiratory Therapy Department at Santa Fe Community College were reviewed and found to be adequately equipped and designed for implementing the clinical evaluation.

Four clinical situations were designed to test for

interpersonal skills via role playing. All the role-playing situations were designed to be videotaped for rating by two or more faculty members. Volunteer actors from Santa Fe Community College would be provided with guidelines for each role-playing situation.













CHAPTER III


INITIAL TESTING OF THE COGNITIVE MODEL



An item analysis of the cognitive model included the following indexes: item difficulty, item discrimination, and test reliability. Initial testing was conducted to determine major strengths and weaknesses of the examination so that revisions could be made prior to using the tests with subsequent groups. The computing facilities at the Office of Instructional Resources, University of Florida, were used to score the examinations and analyze the test items.

Sample Selection and Sample Studied


The decision was made to test the examination with three different groups. Group I, Santa Fe Community College students, had completed all Level I Courses, the seven courses under study, and had previous respiratory therapy experience. Group II, Santa Fe Community College students, had completed Level I Courses but had no previous respiratory therapy experience. Group III was personnel who had clinical experience in respiratory therapy but had no formal respiratory therapy coursework. The rationale for using the three particular groups was that (1) a performance comparison was needed










between students who had completed the seven courses and subjects without any Level I coursework to determine the equibility of the examination, recognizing that it would be unfair to judge candidates by standards that generic students might not attain, and (2) the writer was interested in performance differences among groups with coursework, experience in the field, and combined coursework and experience in the field. The investigator assumed that no major differences in general intelligence between groups would exist; however, students in the program would be expected to perform better because they had completed the coursework and might be more test-wise than Group III.

The method of sample selection was purposive. Although

this method was not as effective as random sampling, the technique was justified because of the purposes of the initial testing (Kerlinger, 1973).

Nineteen subjects participated in the testing session of the cognitive model. The sample studied consisted of 13 students in the Respiratory Therapy Program at Santa Fe Community College: 5 students were in Group I (experience.and Level I coursework)and 8 students were in Group II (Level L, coursework only). Group III comprised 6 subjects who had no Level I coursework and were currently working as respiratory therapy assistants in Alachua County. The subjects in Group III were volunteers who responded to a letter inviting










all respiratory therapy personnel in Alachua and Bradford Counties in Florida to participate in the testing session.

Initially, 14 respiratory therapy personnel applied to take the examination. After reviewing the objectives from the seven courses under study, 8 respiratory therapy personnel withdrew because they reported that their experiences and knowledge levels were inadequate to prepare them to pass any portions of the cognitive examination.


Hypotheses


The null and research hypotheses for testing the cognitive model were proposed.

1. H 0 No difference in mean scores on the total respira0 tory therapy validation examination (RTVE) will be
found between the three groups.

H a At least one of the three groups differs from the
a others with respect to mean scores on the total RTVE.

2. H 0 No difference in mean scores on Section I of the
0 RTVE will be found between the three groups.
H a At least one of the three groups differs from the
a others with respect to mean scores on Section I
of the RTVE.

3. H 0 No difference in mean scores on Section II of the
RTVE will be found between the three groups.

H a At least one of the three groups differs from the
a others with respect to mean scores on Section II
of the RTVE.

4. H 0 No difference in mean scores on Section III of the
RTVE will be found between the three groups.
H a At least one of the three groups differs from the
a others with respect to mean scores on Section III
of the RTVE.










5. H : No difference in mean scores on Section IV of the
0 RTVE will be found between the three groups.
H a At least one of the three groups differs from the
a others with respect to mean scores on Section IV
of the RTVE.

6. H 0 No difference in mean scores on Section V of the
0 RTVE will be found between the three groups.

H a At least one of the three groups differs from the
a others with respect to mean scores on Section V
of the RTVE.

7. H : No difference in mean scores on Section VI of the
0 RTVE will be found between the three groups.

H a At least one of the three groups differs from the
a others with respect to mean scores on Section VI
of the RTVE.

8. H : No difference in mean scores on Section VII of the0 RTVE will be found between the three groups.

H : At least one of the three groups differs from the
a others with respect to mean scores on Section VII
of the RTVE.


The rejection region was established: reject the null hypotheses if H exceeds the tabulated value of chi square for E< .05 and 2 degrees of freedom.



Methodology

The examination consisted of 210 multiple-choice items and was divided into seven sections to represent content for each of the seven courses. An examinee must score satisfactorily on a section to quality for the respective clinical examination. The rationale underlying this policy was a belief by respiratory therapy faculty that all respiratory










therapists should be able to perform academically at the community college level, since higher level verbal and mathematical skills are required to practice respiratory therapy effectively. The examination items were distributed as displayed in Table 2.


Table 2

Distribution of Test Items


Number %
Course Test Total Items Test
RS 101 Introduction to Respiratory Therapy 26 12.38 RS 121 Medical Gas Therapy 26 12.38 RS 122 Humidity Therapy 25 11.91 RS 123 Intermittent Positive Pressure 25 11.91
Breathing
RS 141 Respiratory Therapy Pharmacology 26 12.38 RS 151 Cardiopulmonary Resuscitation 30 14.28 RS 250 Cardiopulmonary Anatomy and
Physiology 52 24.76 Total 210 100



RS 250 was assigned more weight for the written examination because the course content did not lend itself to clinical evaluation. For most five-response multiple-choice formats, examinees should be able to respond to an item in 60 seconds or less (Mehrens and Lehmann, 1973).

The examination was not considered to be a test of speed. All examinees were allowed time to complete all test items. Projected completion time for the examination was three and one-half hours. All items were given equal weight. Following









recommended testing protocol (Mehrens and Lehmann, 1973), examinees were instructed to answer as many questions as possible and were informed they would not be penalized for guessing. A correction formula for guessing was not used. Names of the examinees were known only by the examiner; each examinee was assigned a number to reduce the threat for respiratory therapists who were working in Alachua or Bradford county.

Examinees granted permission to code the following

information on the response sheets for storage on computer tape and use in future analyses: social security number, birth date, sex, number of years of education, number of years of respiratory therapy experience, group membership (1, 2, or 3), and Florida Twelfth Grade Achievement Test (FTGAT) scores.

The FTGAT scores were recorded on all individuals who completed high school in Florida in order to provide a common index of academic ability of the examinees. Subjects with high scores (400 or more) would be expected to be more test-wise (Goolsby, 1967) and perform better on the RTVE.

All students and respiratory therapy personnel that

participated in the examination had access to all objectives of the seven courses under study. Respiratory therapy personnel were mailed copies of the objectives six weeks prior to the testing date.










The examination was administered to 18 subjects at the same time, under the same testing conditions. One subject

-was unable to attend the group testing but was administered the test later, under similar conditions. Times to complete the examination ranged from 1 hour and 40 minutes to 3 hours and 20 minutes; most examinees completed the test in 2 hours and 15 minutes.


Item Analysis


Using the optical scanner and computing facilities at

the University of Florida, the examination data were analyzed .by determining the following indexes: item-by-item response display, item difficulty, item discrimination, descriptive statistics, and Kuder-Richardson estimate of reliability (formula 20).
Although a larger sample was desirable but inaccessible, the data obtained revealed important trends and information about the 210 examination-items and the 19 subjects who participated in the initial testing.

Table 3 shows the range of scores, mean, median, mode,

standard deviation, standard error, and reliability index for the total examination. The mean, median, and modecoincide (124), suggesting a normal distribution. The range (93-155) depicts adequate variance. Using the standard error of measurement (S e), a person's true score on the Respiratory Therapy Validation Examination (RTVE) can be predicted to be










within � 1.96 Se (5.91) of the observed score, 95% of the time. The reliability index for the total examination is desirably high (.88). Although agreement is-not universal, in general tests used in making important decisions about individuals should have reliability coefficients of .85 or greater (Noll and Scannell, 1972). Kuder-Richardson's formula 20 provides an estimate of internal consistency and also explains to what extent the observed variance is due to true-score variance (Mehrens and Lehmann, 1973).



Table 3

Descriptive Statistics of Examinees'
Total Scores on the RTVE


Total number of examinees 19.00 Total number of items on exam 210.00 Range of scoresHigh = 155.00 Low = 93.00 Highest possible score 210.00 Mean raw score 124.00 Median raw score 124.00 Mode raw score 124.00 Standard deviation (raw score) 17.07 Standard error of measurement 5.91 Kuder-Richardson's Reliability Index (formula 20) .88



Even more important than test reliability, was validitydid the instrument measure what it was intended to measure? Because the 210 test items were based on specific course objectives and the Tables of Specifications (Appendix C), the RTVE possessed content validity. "There is no commonly









used numerical expression for content validity: It is determined by a thorough inspection of the items" (Mehrens and Lehmann, 1973, p. 124). Four respiratory therapy judges and one test construction consultant reviewed the examination and course objectives to verify the content validity of the cognitive model.

Appendix D depicts descriptive data and frequency distribution of scores on the total RTVE. Ideally, samples larger than 30 should be used so that chances of approaching a normal distribution are increased (Noll and Scannell, 1972). Because of the small sample, the difficulty and discrimination indexes must be evaluated cautiously and viewed as contextual to the content of the test items and course objectives.

Review of the item difficulty indexes revealed a wide

range (.00 to 1.00), indicating that on 3 items, all students answered incorrectly and on 12 items, all examinees responded correctly. The investigator and the coordinator of the Respiratory Therapy Program reviewed the test items that were too easy (greater than .70) and too difficult (less than '40) to determine whether the items should be revised or deleted. An ideal average difficulty index for a maximally discriminating test, using the five-response, multiple-choice format, is .40 to .70 (Mehrens and Lehmann, 1973). A total of 26 test items were revised by making minor changes in the stems, answers, or distracters to clarify ambiguous or misleading items. The problem cannot be resolved by examining the










indexes alone. If all examinees responded correctly to objectives that should be mastered, then the items should be retained but examined carefully to improve the discrimination indexes.

For most tests with samples of less than 30 examinees,

a discrimination index of .20 is adequate (Noll and Scannell, 1972) to discern the high-performers from the low-performers. Items with negative discrimination indexes were reviewed and revised to improve the quality of the stems, answers, and distracters; these were, for the most part, the same 26 items that had undesirable difficulty indexes. A total o.f 50 test items had discrimination indexes less than .20. A larger sample would have yielded higher discrimination indexes.

No further revisions were indicated until the examination had been tested with 60 or more students. None of the test items was deemed to be of such poor quality to require deletion.

An important point to keep in mind when examining an

item analysis is that the data obtained applies to the particular group that participated in the testing session and are not necessarily generalizable beyond the sample tested (Noll and Scannell, 1972).











Data Presentation and Analyses


Descriptive data and total scores of examinees on the

RTVE by groups are displayed in Table 1. Fourteen males and five females participated in the testing. The mean age of examinees was 25.5 years. Subjects in Group III were, on the average, 3 years older than subjects in Group I and Group II. No notable differences were found in years of formal education. Four subjects in Group III had attended community or senior colleges in non-respiratory related fields. Subject 2, in Group III, had a master's degree in education and also had the greatest number of years of experience in respiratory therapy. Group III had a mean of 6.66 years experience in respiratory therapy as compared to a mean of 2.2 years for Group I. Examinees with experience and respiratory therapy coursework (Group I) scored highest on the RTVE and Group III (experience but no respiratory therapy coursework) obtained the lowest mean score on the RTVE.

Subjects who had scores of 400 or greater on the FTGAT achieved the highest scores on the RTVE. The product-moment correlation between the 10 available FTGAT scores and respective total scores on the RTVE (Table 5) was high (r= .8138). The amount of variance in scores on the RTVE that could be explained by r2 was 66% (r2= .6622). The correlation between the two tests was not causal but indicated that persons who scored high on one of the variables would probably score high on the other variable (Hays, 1973).












Table 4

Descriptive Data and Total Scores of Examinees
on the RTVE by Groups


Years of Years of RTVE FTGAT Group N Age Sex Education RT Experience Scores Scores
I 1 24 N 13 3 155 459
2 22 D 14 2 149 486
Q 3 30 M 14 1 1390 r 4 22 F 13 1 136 411
5 26 F 14 4 128
5 CM 24.80 13.60 2.20 141.40 452.00 o X
U w
II 1 23 M 14 0 143 411
2 22 F 13 0 125
3 31 M 15 0 124 --4 22 1 13 0 124 365 o 5 27 M 13 0 118
6 20 F 13 0 118 329 �o 7 23 F 14 0 116 359
0 8 29 N 13 0 116
M 24.62 13.50 0 123.00 366.00

III 1 28 M 14 6 145 --2 35 II 16 12 113 --3 23 M 13 7 109 375 o 4 24 M 12 5 107 --5 23 M 13 2 98 373 P F: 6 31 14 14 8 93 175
M 27.33 13.66 6.66 110.83 307.66


Grand Me an


25.55


13.57


124.00 374.30


*Graduated from non-Florida high school.










Table 5

Scattergram Depicting Correlation Between FTGAT and RTVE Scores 500

450

400- 9

350- �

FTGAT 300

250 200.

150


90 100 1i0 120 130 140 150 160 RTVE

The probability that the product-moment correlation (r= .8318) between FTGAT and RTVE scores did not occur by chance is significant at p< .05,
8 df (Popham, 1967, p. 396).



Because the small sample size and unequal group sizes posed a threat of violating the assumptions of parametric analysis of variance, the Kruskal-Wallis test was used to analyze variance among groups (Hays, 1973). The Kruskal and Wallis procedure is a nonparametric, one-way analysis of variance and can be effectively used for experimental and nonexperimental data (Kerlinger, 1973). Scores in each group are ranked, then the rank-sum attached to each separate group is found. T. = the sum of ranks for group j and T is the
J










sum of these rank sums. If the ranking was done correctly, then

T - N(N+l) (Hays, 1973, p. 783).
2

The formula used to test each hypothesis is


H 12 l K -3(N+l) (Hays, 1973, p. 783).
H=N(N+l) i jI


The values of Hwere referred to the chi-square distribution with 2 degrees of freedom for testing the null hypotheses that all J score distributions were identical for the entire examination and the seven section examinations. From the chi-square distribution, the critical level for rejecting the null hypotheses at p< .05 and 2 degrees of freedom, was 5.99 (Hays, 1973, p. 887).

Tables 6-13 display the group means, grand means, and H values for the total examination and the seven separate course examinations. Significant differences were found among the groups for the total examination (Table 7) and four of the section examinations (Tables 7, 8, 12, and 13).














Table 6

Analysis of Group Performance
on the Total RTVE


Group I Group II Group III
Coursework Coursework Experience
and Only Only
Experience
Score Rank Score Rank Score Rank 155 1 143 4 145 3 149 2 125 8 113 15 139 5 124 9.5 109 16 136 6 124 9.5 107 17 128 7 118 11.5 98 18 118 11.5 93 19 116 13.5
M 141.4 T. 21 M 123 T. 81 M 110.83 T. 88
J J J

T 441 T2 6P61 T = 7744
J J J
n=5 n=8 n=6


H = 9.4416, significant at p< .05, 2 df.

Grand mean for all subjects on the RTVE = 124 (highest possible score - 210).














Table 7

Analysis of Group Performance on Section I
Introduction to Respiratory Therapy


Group I Group II Group III
Coursework Coursework Experience
and Only Only,
Experience
Score Rank Score Rank Score Rank 24 2.5 26 1 22 7 22 7 24 2.5 19 14 22 7 23 4 18 16 20 11.5 22 7 17 17 19 14 22 7 16 18 21 10 14 19 20 11.5
19 14
M 21.4 T. 42 M 22.12 T. 57 M 17.66 T. 91
SJ J
T 1764 T 3249 T 8281
J )J J ,8
n=5 n=8 n=6


H = 7.5501, significant at p< .05, 2 df.
Grand mean for all subjects on Section I = 20.52 (highest possible score - 26).














Table 8

Analysis of Group Performance on Section II
Medical Gas Therapy


Group I Group II Group III
Coursework Coursework Experience
and Only Only
Experience
Score Rank Score Rank Score Rank

18 2 17 4 16 6
18 2 16 6 12 11.5
18 2 13 9.5 11 14
16 6 13 9.5 10 16.5 14 8 12 11.5 7 18.5 11 14 7 18.5 11 14
10 16.5
M 16.8 T. 20 M 12.87 T., 85 M 10.5 T. 85

T 400 T 7,225 V 7,225
J J J
n=5 n=8 n=6


H = 9.0723, significant at p< .05, 2 df.


Grand mean for all subjects on Section II = 13.15 (highest possible score - 26).














Table 9

Analysis of Group Performance on Section III
Humidity Therapy


Group I Group II Group III
Coursework Coursework Experience
and Only Only
Experience
Score Rank Score Rank Score Rank 21 1 15 4 14 7 17 2 15 4 14 7 15 4 14 7 13 10 13 10 13 10 11 13 11 13 11 13 9 17
10 15.5 8 18.5 10 15.5
8 18.5
M 15.4 T. 30 M 12 T. 87.5 M 11.5 T. 72.5

T2 900 T2 7656.25 T2 5256.25
J .J 3
n=5 n=8 n=6


H = 3.57, nonsignificant at p< .05, 2 df.

Grand mean for all subjects on Section III - 12.73 (highest possible score - 26).













Table 10

Analysis of Group Performance on Section IV
Intermittent Positive Pressure Breathing


Group I Group II Group III Coursework Coursework Experience and Only Only Experience

Score Rank Score Rank Score Rank


1.5


3.5 3.5


16 16 15


1.5 9.5 9.5 9.5


9.5


I 17 T. 53.5
3
T2 2,862.5

n=5


15 18
M 17.25 T. 74.5
J
T2 5550.25
3
n=8


1 17 T. 62
J
T2 3,844
3
n=6


H = .2193, nonsignificant at p< .05, 2 df.

Grand mean for all subjects on Section IV = 17.1 (highest possible score - 25).














Table 11

Analysis of Group Performance on Section V
Respiratory Therapy Pharmacology


Group I Group II Group III
Coursework Coursework Experience
and Only Only
Experience
Score Rank Score Rank Score Rank 17 2 13 7 22 1 18 3 13 7 13 7 14 4 13 7 11 14 12 11 13 7 9 16
11 14 12 11 8 17.5 12 11 6 19 11 8
8 17.5
M 14.8 T. 34 H 11.87 T. 81.5 M 11.5 T. 74.5

T 1 156 V 6,642.25 T 5,550.25
J J J
n=5 n=8 n=6


H = 2.7323, nonsignificant at p< .05, 2 df.

Grand mean for all subjects on Section V = 12.52 (highest possible score - 26).














Table 12


Analysis


of Group Performance on Section VI Cardiopulmonary Resuscitation


Group I Group II Group III
Coursework Coursework Experience
and Only Only
Experience
Score Rank Score Rank Score Rank 23 1.5 22 3.5 21 5
23 1.5 19 8.5 19 8.5 22 3.5 18 11.5 18 11.5 20 6.5 17 15 18 11.5 20 6.5 17 15 18 11.5 17 15 16 17.5 16 17.5
13 19
M 21.6 T. 19.5 H 17.37 T. 105 M 18.33 T. 65.5
J J
T2 380.25 T 11,025 T 4290.25
J J j
n=5 n=8 n=6


H = 8.504, significant at )< .05, 2 df.

Grand mean for all subjects on Section VI = 18.78 (highest possible score - 30).















Table 13

Analysis of Group Performance on Section VII
Cardiopulmonary Anatomy and Physiology


Group I Group II Group III
Coursework Coursework Experience
and Only Only
Experience
Score Rank Score Rank Score Rank 37 1.5 37 1.5 33 6 36 3 33 6 26 13 34 4 32 8.5 25 15
33 6 29 10 23 16.5
32 8.5 28 11 21 18 26 13 18 19 26 13
23 16.5
M 34.4 T. 23 M 29.25 T. 79.5 M 22.66 T. 87.5

T 529 T 6,320.25 T 7656.25
J J J
n=5 n=8 n=6


H 8.5854, significant at p< .05, 2 df.

Grand mean for all subjects on Section VII = 29.05 (highest possible score - 52).










Section I - Introduction to Respiratory Therapy (Table 7)

Section II - Medical Gas Therapy (Table 8)

Section VI - Cardiopulmonary Resuscitation (Table 12)

Section VII- Cardiopulmonary Anatomy and Physiology (Table 13)


Therefore, the null hypotheses (1, 2, 3, 7, and 8) were rejected and the research hypotheses (1, 2, 3, 7, and 8) accepted. Null hypotheses (4, 5, and 6) could not be rejected, since no significant differences in mean scores were found among the groups.

Examination of group means on the total examination and the seven course examinations revealed some interesting and unexpected findings. Group I scored higher than Groups II and III on the total examination and on the following course examinations:

Section II - Medical Gas Therapy

SectionIII - Humidity Therapy

Section V - Respiratory Therapy Pharmacology

Section VI - Cardiopulmonary Resuscitation

Section VII - Cardiopulmonary Anatomy and Physiology

The test content of the five courses listed above demanded not only recall of important facts but required the examinee to apply facts to problem-solve and make difficult, clinical judgments. The clinical experience of subjects in Group I may have enhanced the knowledge gained from their coursework at Santa Fe, thus, accounting for their higher performance.










Also, the FTGAT scores of subjects in Group I suggested that overall, they were more test-wise than examinees in Groups II and III.

Group II scored higher than Groups I and III on Section

I (Introduction to Respiratory Therapy) and Section IV (Intermittent Positive Pressure Breathing). Groups I and III may have had negative work experiences in these two areas, possibly acquiring inaccurate information, that accounted for their lower performance. The test-content of Section I demanded recall of information that respiratory therapists needed to know about the AART to pass the national registry examination. Intermittent Positive Pressure Breathing has been an area of controversy within the field and practices vary widely from hospital to hospital. The quaZity of experience no doubt played an important factor in either supplementing theory or adding confusion, depending on whether the experiences were based on sound principles of practice.

Group III scored higher than Group II on Section VI (Cardiopulmonary Resuscitation) and equally as well as Group I on Section IV (Intermittent Positive Pressure Breathing). Most subjects in Group III had participated in cardiopulmonary resuscitation in the hospital setting and had attended periodic inservice training programs to improve their skills in life-saving techniques.

The coordinator of the Respiratory Therapy Program and the investigator established that the grand mean of the 19










subjects on each section examination would be the criterion for acceptable performance; this decision was based on the belief that candidates applying for advanced standing should be evaluated according to the mean performance of generic students on the sever course examinations. Thus, if subjects in Group III scored the grand mean or higher ona section, then they qualified to take the respective clinical examination.

Using the above criterion, the following courses were

passed by the number of examinees listed below, according to group membership. Percentages of each group that passed are shown in parentheses (Table 14).


Table 14 Courses Passed by


Group Members


Group I Group II Group III Coursework Coursework Experience Course and Only Only Experience
Introduction to Respiratory Therapy 4 (80%) 8 (100%) 1 (16.6%) Medical Gas Therapy 5 (100%) 7 (87.5%) 1 (16.6%) Intermittent Positive
Pressure Breathing 2 (40%) 5 (62.5%) 4 (66.6%) Humidity Therapy 4 (80%) 4 (50%) 3 (50%) Respiratory Therapy
Pharmacology 3 (60%) 6 (75%) 2 (33.3%) Cardiopulmonary
Resuscitation 5 (100%) 3 (37.5%) 5 (83.3%) Cardiopulmonary Anatomy and Physiology 5 (100%) 5 (62.5%) 1 (16.6%)










One examinee in Group III attained the third highest score on the total examination and also passed the seven course examinations; this person was reported to be an outstanding worker, with six years of experience in the field, who was eager to learn new techniques and theory and often attended continuing education programs in respiratory therapy.

Students in Groups I and II purported to have spent little or no time preparing for the examination because they were too busy studying for final examinations. In general, respiratory therapy personnel reported they had tried to review as many of the objectives as possible. Thus, it was difficult to account for variance in scores due to individual variances in preparation for the examination.


Conclusions


Item analysis and review of the groups' performances on the cognitive model served to identify strengths and weaknesses of the examination. Although the reliability of the examination was acceptably high (.88), the previously mentioned revisions should serve to increase the reliability and improve questions that were ambiguous or specious.

The cognitive model appeared to be an appropriate,

diagnostic method for identifying experienced respiratory










therapy personnel, who have adequate theoretical knowledge in the field, to qualify to take the clinical examination.

Until the cognitive model has been tested with larger

samples, no further revisions were deemed necessary. Future item analyses will assist examiners in constructing a large file of the best test-items to include in future testing models.

The analysis of variance indicated whether there were significant differences in knowledge among groups. With larger samples, parametric analysis of variance could be employed and if significant differences were found, then an appropriate t-test, such as Schefe's, could be applied to discern where significant differences among groups occurred (Hays, 1973).













CHAPTER IV


EVALUATING THE CLINICAL MODEL



Three male subjects who had passed one or more sections of the cognitive examination were available to take the clinical examination. Subjects volunteered to takeall five portions of the clinical examination so that the feasibility of the entire model could be evaluated. The courses tested were

RS 101 - Introduction to Respiratory Therapy
RS 121 - Medical Gas Therapy
RS 122 - Humidity Therapy
RS 1231_ {Intermittent Positive Pressure Breathing
RS 141} {and Respiratory Therapy Pharmacology
RS 151 - Cardiopulmonary Resuscitation


Prior to testing the clinical model, the test situations and equipment and personnel schedules were reviewed to guarantee that examinees would have the proper support to perform the expected affective and psychomotor skills. The respiratory therapy teaching laboratory was arranged to examine candidates for psychomotor skills and a classroom was designed with the necessary equipment to simulate a hospital room so that affective skills could be examined. The classroom was also equipped with a camera and audiovisual accessories for videotaping the role-playing situations.










All participating faculty examiners, actors, and the camera technician were briefed regarding the examination checklist, sequence of events, and behaviors expected of the actors, examinees, and examiners. A trial run was conducted to affirm that all equipment was in place and functioning properly. One faculty member was stationed in the laboratory to test for psychomotor skills and the other faculty member, actors, and camera technician were in the simulatedhospital room to test for affective skills. Only one examinee could be tested at a time, in each room. Total time to complete the entire clinical examination was approximately 90 minutes: 20 minutes for the affective skills and 70 minutes for the psychomotor skills. The critical time limits imposed for all of the testing situations in the clinical model totals 79 minutes but additional time is required to "set the stage" after an examinee has completed a section. The critical time limits were established by the four respiratory therapy faculty members and the investigator; all examinees were able to perform within the established time limits. No problems were encountered during the testing of psychomotor skills.

The three subjects who participated in the clinical

examination had little or no previous experience with roleplaying. The examiners and actors "set the stage" for each simulation and allowed the examinees time to mentally prepare themselves for the situation. The three role-playing










situations were videotaped for analysis by three respiratory therapy faculty to obtain inter-rater reliability. A checklist of expected behaviors was used for the role-playing situations that aimed to measure prespecified qualities of-. the examinee: listening ability, verbal expression, empathy, appropriateness of response to emotional cues, and judgment. All subjects performed satisfactorily during the role-playing situations.

The highest possible score a subject could attain on the clinical model was 312. The lowest possible score a subject could receive and still pass all 5 sections, including critical skills, was 234. The subjects' scores were 216, 261, and 281. Each section of the clinical model had to be evaluated separately to discern whether the examinee passed the required critical skills; if any portions of the critical skills were not met, then the examinee failed that particular section. Only one of the role-playing situations was designated a critical skill, the rationale being that the specified situation was one often encountered in hospitals and competent respiratory therapists would be able to solve the problem effectively.

In addition to performing psychomotor and affective skills, subjects were required to present American Heart Association certificate cards (Level II and V) to document. successful performance of basic and advanced life-sunport skills in cardiopulmonary resuscitation. The American Heart










Association has offered courses locally to certify persons to perform cardiopulmonary resuscitation at five different levels: Level I (a basic course for lay persons) to Level V (the most advanced course for health professionals).

Future testing of affective skills, utilizing roleplaying, will be required to evaluate the validity and reliability of the clinical model for measuring desirable qualities that are required of competent respiratory therapists. Critics may argue that the checklists used in the clinical model were not completely behavioral nor were they totally objective. The examiner must make a judgment as to whether the behavior occurred and if it did, must decide how well the examinee performed. Astute observational skills were required of examinees and because of the element of subjectivity, the inter-rater reliability method was used to score the role-playing situations.

The clinical model represented an initial effort to quantify and measure critical psychomotor and affective skills of respiratory therapy personnel applying for advanced standing. Merhens and Lehmann reported a dismal outlook: "Whether or not tests of noncognitive variables will ever be successful as selection instruments is debatable because the problem of faking will always exist to some degree" (1973, p. 677). Although measurement in the affective domain was the most difficult task, educators cannot continue to ignore this important area of instruction and evaluation. With










future trials of the clinical model, no doubt the measurement techniques can be refined.



Recommendations for Future Research and Utilization


Findings of the study supported the continued development and use of validation examinations for respiratory therapy personnel applying for advanced placement to the respiratory therapy program at Santa Fe Community College. The validation examinations provided formal mechanisms for granting academic credit and advanced placement. Based on initial testing and evaluation of the cognitive and clinical models, the following recommendations for further research both at Santa Fe and in related programs were proposed:

1. Perform several testing sessions with similar groups of students, as used in the present study, so that appropriate measures can be taken to improve the validity and reliability of the cognitive and clinical models. Analyses of examinations by computer and storage on magnetic tape will provide a useful data bank for future testing with subsequent groups and will also help to accumulate a test file of the best items to include in future examinations.

2. Periodically update the examinations whenever course objectives are revised to maintain content validity of the examinations. Most achievement tests have been criticized because they do not reflect the educational objectives of the










program (Tyler and Wolf, 1974). Because the cognitive and clinical models were based on objectives of the first-year Respiratory Therapy Program at Santa Fe Community College, they do possess content validity and are appropriate instruments for assessing knowledge of candidates applying for advanced standing.

3. Use objectives from the seven courses under study to assess a candidate's readiness to take the validation examination, identify specific strengths and weaknesses of applicants and prescribe learning activities to enhance chances of successful performance on the examinations.

4. Grant advanced placement to candidates who pass one or more sections of the validation examinations and assist them to either continue an individualized, formal program of study or join generic students at the appropriate course level.

5. Employ the cognitive and clinical models annually or semiannually for summative-type evaluations of generic students in the respiratory therapy program to assess progress and effectiveness of the instructional program. Compare students' achievement on the examinations later with their performance on the national registry examination to provide follow up and accountability (Ryan, 1975).

6. For the more advanced courses offered during the second year of the respiratory therapy program, develop a branching examination that tests primarily for clinical problemsolving skills and serves as an alternative to the multiplechoice format (Mehrens and Lehmann, 1973).










7. In future cognitive models, incorporate an additional type testing format: the use of well-constructed essay tests to provide a means of testing an examinee's ability to compose a logical answer and present it in an acceptable, written style. Evaluators must keep in mind that, contrary to popular belief, no evidence exists to support the claim that only the essay test can be used to measure higher mental processes of organization, analysis, and evaluation (Mehrens and Lehmann, 1973, p. 213).

8. Since test-wise students are likely to perform higher on the cognitive examination, direct candidates who have a previous record of poor performance on national achievement examinations such as the FTGAT or the SAT, to improve their test-taking skills via one or more methods:

a. independent study of textbooks designed to
help persons become more test wise (Millman
and Paulk, 1969 or Juola, 1968).

b. enrollment in specially-designed night courses
that assist students in improving test-taking
skills and overcoming test anxiety.

9. Consider that many respiratory therapy personnel may have been denied admission to academic programs because they could not meet entry-requirements or pass standard achievement examinations used in the selection of students. The proposed cognitive and clinical testing models were designed to accommodate varied learning and performance styles of examinees. Previous researchers have proposed that the cognitive styles of learners be identified to plan individualized instruction











(Nunney, 1975). For future research, include the identification of examination-performance styles of individuals, thus offering alternative forms of testing to candidates who are clinically proficient but unable to perform well on cognitive examinations.

10. With permission of the examinees who participated

in the role-playing situations, use the videotapes for either instructional or evaluation purposes. A student might be asked to view the role-playing situation and identify the correct or incorrect practices performed by the therapist. This technique offers an alternative assessment procedure, if role playing is later judged to be an unreliable method of testing affective skills.

11. Employ the videotapes for teaching interpersonal

relationships to generic students in the respiratory therapy program (Tansey, 1971). Construct teaching files of roleplaying situations to provide students with models of behavior that are expected of respiratory therapists.










Summary


Important decisions are frequently made on the basis of one or more types of achievement examinations, such as granting advanced placement to successful candidates or admitting students to academic programs. For this reason, educators must know whether the examinations that were employed in decision making were given the correct emphasis and if the evaluation instruments provided accurate assessments of examinees' knowledge and performance levels. Examinations that fail to possess adequate validity and reliability must be rejected, especially where decisions are made regarding a person's educational future. As a result of inadequate, evaluation procedures, many qualified persons may be "sorted out" and labeled "undesirable."

Evaluation must not be viewed, in this context, as a punitive procedure but as a diagnostic, prescriptive, and therapeutic process that was intended to assist individuals in achieving attainable career goals.

The cognitive and clinical models that were developed in the present study represented initial efforts to provide formal mechanisms for granting academic credit and advanced placement to qualified respiratory therapy personnel; the models applied only to the respiratory therapy courses offered the first year at Santa Fe Community College.










Using the Kruskal-Wallis nonparametric analysis of variance procedure, significant differences in mean performance on the total respiratory therapy validation examination and four section examinations were found (p <.05). Therefore, the following null hypotheses for the cognitive model were rejected and the research hypotheses accepted:

1. H : No difference in mean scores on the total respira0 tory therapy validation examination (RTVE) will
be found between the three groups.

H : At least one of the three groups differs from the
others with respect to mean scores on the total
RTVE.

2. H No difference in mean scores on Section I of the
0 RTVE will be found between the three groups.
H a: At least one of the three groups differs from the
others with respect to mean scores on Section I
of the RTVE.

3. H : No difference in mean scores on Section II of the
0 RTVE will be found between the three groups.

H a: At least one of the three groups differs from the
others with respect to mean scores on Section II of
the RTVE.

7. H : No difference in mean scores on Section VI of the
RTVE will be found between the three groups.

H : At least one of the three groups differs from the
a others with respect to mean scores on Section VI
of the RTVE.

8. 11 : No difference in mean scores on Section VII of the
RTVE will be found between the three groups.

H : At least one of the three groups differs from the
others with respect to mean scores on Section VII
of the RTVE.

With larger samples, parametric analysis of variance

could be employed and if significant differences were found,










an appropriate t-test, such as Schefe's, could be applied to discern where significant differences among groups occurred (Hays, 1973).

Evaluation of both models with candidates provided

evidence that there are respiratory therapy personnel who have acquired adequate knowledge and experience to pass the equivalency examinations and earn academic credit. With the previously mentioned revisions and future testing programs, the validity and reliability of the multidimensional testing models would be improved.

Educational readiness of an academic program and the

program's ability to supply the necessary time, faculty, and expenditures must be assessed before equivalency evaluation is undertaken. Findings of the study warranted the development of equivalency testing models for the respiratory therapy courses offered the second year at Santa Fe Community College.

Increased demands for improvement of health care

delivery to consumers suggest that educators of other allied health programs consider the development and use of validation examinations to encourage health personnel to maintain and upgrade standards of care, while protecting their future in the field.














BIBLIOGRAPHY


Adkins, D.C. Statistics: An introduction for students in the
behavioral sciences. Columbus, Ohio: Charles E. Merrill,
Inc., 1965.

Banathy, B.H. Instructional systems. Belmont, California:
Fearon Publishers, 1973.

Beauchamp, G. Curriculum theory. Wilmette, Illinois: Kagg
Press, 1975.

Bresinski, M.E. Management education opportunities not well
used. Respiratory care, 1975, 20, 718.

Comroe, J.H. Physiology of respiration (2nd ed.). Chicago:
Yearbook Medical Publishers, 1974.

Cronin, M. Internships for respiratory therapy. Respiratory
Therapy, 1976, 6, 39-41, 59.

Davis, R.H., Alexander, L.T. and Yolon, S.L. Learning system
design: An approach to the improvement of instruction.
New York: McGraw-Hill, 1974.

Demers, R.R. Is the respiratory therapist an endangered
species? Respiratory Care, 1976, 21, 620.

DeShaw, B.L. Developing competencies for individualizing
instruction. Columbus, Ohio: Charles E. Merrill, Inc.
1973.

Egan, R. Fundamentals of respiratory therapy. St. Louis:
C.V. Mosby, 1975.

Essentials of an approved educational program for the respiratory therapy technician and the respiratory therapist.
Respiratory Care, 1972, 17, 679-684.

Fehling, E.H. Oral exams should be in clinical settings.
Respiratory Care, 1976, 21, 489.

Ford, C.W. and Morgan, M.K. (Eds.). Teaching in the health
professions. St. Louis: C.V. Mosby, 1976.










Fox, D.J. The research process in education. New York:
Holt, Rinehart and Winston, 1969.

Gage, N.L. Handbook of research on teaching. Chicago:
Rand McNally, 1963.

Gagne, R.M. and Briggs, L.J. Principles of instructional
design. New York: Holt, Rinehart and Winston, 1974.

Goolsby, T.M. Comparability and validity of three forms of
SCAT. Educational Measurement, 1967, 27, 1041-1045.

Hatch, T.D. Allied health manpower-Direction for the 1970s
and 1980s. Respiratory Care, 1971, 16, 7-10.

Hays, W.L. Statistics for the social sciences. New York:
Holt, Rinehart and Winston, 1973.

Helmholz, H.F. Report from the joint review committee for
inhalation therapy education. Respiratory Care, 1972,
17, 692-694.

Irby, D.M. and Dohner, C.W. Student clinical performance.
In Ford, C.W. and Morgan, M.K. (Eds.). Teaching in the
Health Professions. St. Louis: C.V. Mosby, 1976.

Irby, D.M. and Morgan, M.K. (Eds.). Clinical evaluation:
Alternatives for health related educators. Gainesville, Fla.: Center for Allied Health Instructional Personnel,
1974.

Juola, A.E. Examinations (Skills and techniques). Lincoln,
Nebraska: Cliff's Notes, 1968.

Kerlinger, F.N. Foundations of behavioral research. New
York: Holt, Rinehart and Winston, 1973.

Kerr, E.E. Utilization and preparation of personnel to
deliver health care. Respiratory Care, 1971, 16, 41-48.

Kittredge, P. A proposal for recredentialing respiratory
therapists and technicians every five years. Respiratory
Care, 1975, 20, 433-440.

Krathwohl, D., Bloom, B. and Bartram, M. Taxonomy of educational objectives, Handbook II: Affective domain. New
York: David McKay, 1968.

Mager, R.F. Developing attitude toward learning. Palo Alto,
California: Fearon Publishers, 1968.










Mager, R.F. and Pipe, P. Analyzing performance problems.
Belmont, California: Fearon Publishers, 1970.

Mathewson, H.S. The respiratory therapist's role in critical care. Respiratory Care, 1976, 21, 29-32.

McAleer, W.M. Proposal for two routes to certification.
Respiratory Care, 1975, 20, 782.

Mehrens, W.A. and Lehmann, J.J. Measurement and evaluation
in education and psychology. New York: Holt, Rinehart
and Winston, 1973.

Mendenhall, W., Ott, L., and Larson, R.F. Statistics:
A tool for the social sciences. North Scituate, Mass.:
Duxbury Press, 1974.

Mendoza, J. Everyone should be credentialed. Respiratory
Care, 1975,20, 1102.

Millman, J. and Paulk, W. Row to take tests. New York:
McGraw-Hill, 1969.

Noll, V.H. and Scannell, D.P. Introduction to educational
measurement. Boston: Houghton Mifflin, 1972.

Nunney, D.N. Educational cognitive style: A basis for
personalizing instruction. Educational Scientist, 1975,
1, 13-26.

Occupational outlook handbook, 1976-197? edition.
Washington, D.C.: US Government Printing Office, 1976.

Perry, D.F. Constructing useful objectives in respiratory
therapy. Respiratory Care, 1976, 21, 327-332.

Petty, T.L. Pulmonary diagnostic techniques. Philadelphia:
Lea and Febiger, 1975.

Popham, J.W. Educational statistics: Use and interpretation.
New York: Harper and Row, 1967.

Popham, J.W. and Baker, E.L. Sylstematic instruction.
Englewood Cliffs, New Jersey: Prentice Hall, 1970.

Powers, W.E. Upward mobility for anyone who can climb.
Respiratory Care, 1975, 20, 1054-1055.

Powers, W.E. Improving clinical problem-solving performance.
Respiratory Care, 1976a, 21, 229-231.









Powers, W.W. Upward mobility through schools is unnecessary.
Respiratory Care, 1976b, 21, 369.

Publication manual of the American Psychological Association
(2nd ed.). Washington, D.C.: American Psychological Association, 1975.

Radocy, R.C. Quantification of affective behavior. Chicago,
Illinois: Paper presented at the national Council on Measurement in Education, April 18, 1974. (ERIC NO.
ED 090265)

Raths, L.E. Teaching for thinking. Columbus, Ohio: Charles
E. Merrill, 1967.

Redman, R.R. Are oral exams valid? Respiratory Care, 1976.,
21, 252-253.

Respiratory therapy task analysis. Unpublished manuscript,
1975. (Available from Santa Fe Community College, Respiratory Therapy Program, Gainesville, Fla.).

Rosenbaun, P.S. Peer-mediated instruction. New York:
Teachers College Press, 1973.

Ryan, C. Career education: A handbook of funding resources
(3rd ed.). Boston: Houghton Mifflin, 1975.

Sanderson, R. Survey of respiratory therapy manpower in
Florida. Unpublished manuscript, 1976. (Available from
Santa Fe Commnity College Respiratory Therapy Program,
Gainesville, Fla.).

Saposnick, A.B. and Weslowski, W.E. College-hospital financial arrangements for clinical instruction and supervision: A survey. Respiratory Care, 1976, 21, 225-228.

Saylor, J.G. and Alexander, W.M. Planning curriculum for
schools. New York: Holt, Rinehart and Winston, 1974.

Scanlan, C.L. Continuing education in the health professions:
Mandatory or voluntary? Respiratory Care, 1975, 21,
823-827.

Scannell, D.P. and Tracy, D.B. Testing and measurement in
the classroom. Boston: Houghton Mifflin, 1975.

Simon, S.B., Howe, L.W. and Kirchenbaum, H. Values clarification: A handbook of practical strategies for teachers
and students. New York: Hart, 1972.










Stanley, J.C. and Hopkins, K.D. Educational and psychological measurement and evaluation. New Jersey: Prentice
Hall, 1972.

Stufflebeam, D.I., Foley, W.J., Gephart, W.J., Guba, E.G.,
Hammond, R.L., Merriman, H.O. and Provus, M.M. Educational
evaluation and decision making. Itasca, Illinois:
F.E. Peacock Publishers, 1971.

Taba, H. Curriculum development: Theory and practice.
New York: Harcourt, Brace and World, 1962.

Tansey, P.J. Educational aspects of simulation. London:
McGraw-Hill, 1971.

Taylor, J.L. and Walford, R. Simulation in the classroom.
Baltimore: Penguin Books, 1972.

Tyler, R.W. and Wolf, R.M. (Eds.). Crucial issues in testing.
Berkeley, California: McCutchan Publishing Corp., 1974.

Whitacre, J.F. Striving for professionalism. Respiratory
Care, 1971, 16, 277-280.

Whitacre, J.F. Beginnings and development of the AAIT.
Respiratory Care, 1972, 17, 491-493.

Wilson, M.A. Equivalency testing in development of health
practitioners. Journal of Allied Health, 1974, 3, 103-109.

Wilson, M.A. Equivalency. In Ford, D.W. and Morgan, M.K.
(Eds.). Teaching in the Health Professions. St. Louis:
C.V. Mosby, 1976.

Youtsey, J. A proposed mechanism for upward mobility through
the educational programs. Respiratory Care, 1975, 20,
1050-1052.










APPENDIX A


Santa Fe Community College
Credit By Exam Policy


Requirements for credit in a number of college courses may be satisfied by successful completion of either a CLEP exam or a discipline/program area made exam,.when a subject matter or general CLEP exam is not available. Evidence of proficiency in any given subject area, when presented to the'Office of Academic Affairs and discipline/program area, shall qualify a student to request an examination.

The proposed policies for institutional credit by examination are:

A student may not challenge a course if he/she attended that particular course at Santa Fe Community College and received a grade of A, B, C, WI or I if he/she has earned credit for an advanced course in that area. Decisions as to whether or not a student has earned credit for an advanced course in the discipline/program area will be determined by the instructor from the area giving the examination.

Examinations for credit by exam may be attempted by the second time after the lapse of one full academic term beyond the term in which the first attempt was made. A student may not attempt credit by exam more than twice in the same course. Credit by exam will not be available during the period between official college terms or during official college holidays.

Credit by examination will not be counted in the student's load, but will be computed in the current grade point average.

An administrative fee of $15 will be charged prior to each credit by exam attempt.

Students are required to be currently enrolled at Santa Fe in order to challenge a course. At least 15 hours of the degree program, AA or AS, must be completed in the classroom. Upon conclusion of the credit by examination by other than CLEP, a copy of the graded examination shall accompany the credit by examination approval form to Academic Affairs. With the approval of Academic Affairs on the completion of the examination, the request form will be validated and the exam copy filed.











APPENDIX B


The Models-Obtaining Information


Because the cognitive and clinical evaluation models will be used in subsequent equivalency examinations at Santa Fe Community College, the models cannot be included in the study. Investigators who would like to replicate the study may obtain more information about the models and complete copies of all course objectives, from which both testing models were derived, by writing to this address:

Director, Respiratory Therapy Program
Santa Fe Community College
South Campus
Gainesville, Florida 32601






APPENDIX C


RS-101 INTRODUCTION TO RESPIRATORY THERAPY


Course-Content Behavior Required of Learner
Discrimi- Evalua- Weight
Topic nation tion Memory Manual Verbal Assigned History of X 5 Respiration
Organization
of AAR X 5 Role of the X X 10 Respiratory
Therapist
Vital Signs x x X X X 10 Medical Records X X X X X 5 Medical-Legal X X X X 10 Problems
Interpersonal x x x X 25 Relationships
Health Care X x X 10 Teams
Manual CPR X X X X X 20

Total 100
Semester Cr. Hrs. 2








RS-121 MEDICAL GAS THERAPY


Course-Content Behavior Required of Learner
Discrimi- Evalua- Weight
Topic nation tion Memory Manual Verbal Assigned Chemistry and X X X X X 10 Physics of
Oxygen
Gas Storage X X X X 15 and Safety
Systems
Oxygen Therapy X X X X 25 Oxygen Deliv- X X X X X 20 ery Apparatus
Oxygen Analysis X X X X X 15 Other Medical X X X X 10 Gases
Hyperbaric X X X X 5 Oxygenation


Total 100

Semester Cr. Hrs. 4









RS-122 HUMIDITY THERAPY


Course-Content Behavior Required of Learner
Discrimi- Evalua- Weight
Topic nation tion Memory Manual Verbal Assigned Chemistry and X X X X X 20 Physics of Aerosols Indications and X X X X 20 Contraindications of Aerosol Therapy Aerosol x X X X x 15 Generation Aerosol Delivery x x x X X 25 Apparatus and Technique Cleaning X X X X 5 Techniques Sterilization X X X X 10 Techniques Isolation X X X X 5 Techniques

Total 100 Semester Cr. Hrs. 4









RS-123 INTERMITTENTPOSITIVE PRESSURE BREATHING


Course-Content Behavior Required of Learner
Discrimi- Evalua- Weight
Topic nation tion Memory Manual Verbal Assigned History, Indi- X X X 20 cations, and
Contraindications of IPPB IPPB Treatment x x X X X 20

Intermittent x x X X X 30 Positive
Pressure
Ventilators

Instrumentation x x X X X 30



Total 100

Semester Cr. Hrs. 4


I









RS-141 RESPIRATORY THERAPY PHARMACOLOGY


Course-Content Behavior Required of Learner Discrimi- Evalua- Weight Topic nation tion Memory Manual Verbal Assigned Pharmacological X X X X 15 Systems & Conversions

Drug Action and X 20 Reaction

Bronchodilators X X 25 Other Respiratory X X 25 Drugs

Common Cardiac X 10 Drugs

Commonly Used X 10 Drugs


Total 100

Semester Cr. Hrs. 3









RS-151 CARDIOPULMONARY RESUSCITATION


Course-Content Behavior Required of Learner

Discrimi- Evalua- Weight Topic nation tion Memory Manual Verbal Assigned

CPR-Obstructed X X X X X 15 Airway
(Unwitnessed) CPR-Unwitnessed x X X X X 15 Cardiac Arrest, One and Two Resucers
CPR-Witnessed X X X X X 15 Cardiac Arrest Infant x X X X X 15 Resuscitation Advanced Life X x x x X 20 Support
Airway X X X X X 20 Management


Total 100

Semester Cr. Hrs. 2








RS-250 CARDIOPULMONARY ANATOMY AND PHYSIOLOGY


Course-Content Behavior Required of Learner Discrimi- Evalua- Weight Topic nation tion Memory Manual Verbal Assigned Circulatory X X X 15 Anatomy & Physiology Respiratory X X X 15 Anatomy and Airway Physiology Mechanics of X X X 20 Ventilation Gas Transport X X X 20 in The Blood Blood Gas X X X 20 Interface and
Blood/Tissue Gas Exchange Regulation of X X X 10 Ventilation


Total 100

Semester Cr. Hrs. 3











APPENDIX D


DESCRIPTIVE DATA OF RTVE SCORES


INSTRUCTOR


MOODY NUMBER OF STUDENTS TAKING TEST


TOTAL NUMBER OF ITEMS ON EXAM COURSE NAME SFCC RESP.RANGE OF SCORES -- HIGH =
THERAPY -- LOW =


DEPARTMENT OF


TEST TITLE


HIGHEST POSSIBLE SCORE MEAN (AVERAGE) RAW SCORE MEDIAN (MIDDLE) RAW SCORE


DATE OF EXAM DEC 1976 STANDARD DEVIATION (RAW SCORE) KUDER-RICHARDSON 20 CORRELATION


19.00 210.00 155.00 93.00 210.00 124.00 124.00 17.07 0.88


ALL SCORES AND STATISTICS COMPUTED ON THIS
PAGE ARE BASED ON RAW SCORE.















FREQUENCY DISTRIBUTION OF RTVE SCORES


RAW PERCENT FRESCORE SCORE QUENCY


44.28 46.66 50.95 51.90 53.80

55.23 56.18 59.04 59.52 60.95

64.76 66.18 68.09 69.04 70.95

73.30


z
SCORE

-1.81
-1.52
-0.99
-0.87
-0.64

-0.46
-0.35
0.00 0.05 0.23

0. 70 0.87 1.11
1.23 1.46


93 98 107 109 113

116 118 124 125 128

136 139 143 145 149

155


PERCENTILE
RANK

0.00 5.26
10.52 15.78
21.05

31.57 42. 10 52.63
57.89 63.15


NUMERI CAL
RANK

19 18
17 16 15

13 11
9 8
7


68.42 73.68 78.94 84.21 89.47

94.73


1 1.81













BIOGRAPHICAL SKETCH


Linda Elizabeth Moody was born in Tampa, Florida on

June 30, 1941. She was graduated from Brandon High School in 1959 and received a diploma to practice professional nursing from Gordon Keller School of Nursing in 1962.

Pursuing her nursing career at the University of

Florida, she earned a Bachelor of Science degree in Nursing in 1965. Upon graduation, she served for three years in the U.S. Army Nurse Corps at the following installations: Walter Reed Army Hospital, Washington, D.C., 85th Evacuation Hospital, Quinhon, Vietnam, and, U.S. Army Recruiting Center, Jacksonville, Florida.

After earning the Master of Nursing degree in 1969

from the University of Florida, she remained and taught there for four years in the College of Nursing. Because of her special interest in pulmonary diseases, the Florida Lung Association granted financial support for postgraduate study at the University of Arizona, where she received a certificate as a Pulmonary Clinical Nurse Specialist in December, 1972.

Since 1973, she has been employed as a Pulmonary

Clinical Nurse Specialist at the Veterans Administration Hospital, Gainesville, Florida. Several of her articles regarding pulmonary care have been published in national nursing






83



and medical periodicals. Memberships in professional organizations include Sigma Theta Tau, Pi Lambda Theta, Kappa Delta Pi, American Nurses' Association, and Outstanding Young Women of America.









I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.



I )
MargarA K. Morgan, Chairman Associate Professor of
Curriculum and Instruction



I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.



Amanda S. Baker
Associate Professor of Nursing



I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy

/


James W. Hensel
Professor of Curriculum
and Instruction



I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.


Godon D. Lawrence Associate Professor of Curriculum and Instruction










I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.




Carol E. Taylorj
Assistant Professor of Nursing


This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate Council, and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy.


March 1977



Dean, College of Educ ion


Dean, Graduate School




Full Text

PAGE 1

RESPIRATORY THERAPY VALIDATION EXAMINATIONS: A COMMUNITY COLLEGE MODEL By LINDA ELIZABETH MOODY A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1977

PAGE 2

ACKNOWLEDGMENTS I am particularly indebted to Professor Margaret K. Morgan who was mainly responsible for my involvement in this study and, as chairwoman of my committee, provided substantial support and encouragement. To the members of my committee, Professors James W. Hensel, Amanda S. Baker, Gordon D. Lawrence, and Carol E. Taylor, I am also deeply grateful. Appreciation is due the following faculty members at Santa Fe Community College for assisting me in implementing the testing models: Ronald H. Sanderson, Robert W. Cornelius, Carol B. Swewczyk, and David A. Desautels. My special gratitude is extended to Professors Wilson H. Guertin and Ronald G. Marks for their advice regarding the research design and analysis and to Sue M. Legg and Arlene D. Barry for their reviews of the examinations and assistance with the item analysis. I owe significant debts to Gloria J. Nunley, Chief of the Nursing Service at the Veterans Administration Hospital, Gainesville, Florida, whose assistance in arranging my leave of absence was vital to completing this study, to the members of the University of Florida Division of Pulmonary Medicine, headed by Dr. Alan J. Block, for sharing their knowledge of

PAGE 3

pulmonary medicine and to my typist, Edna B. Larrick, for her unlimited patience and expertise. My love and appreciation are extended to my husband, Edwin H. Holmes, Jr., my parents, Mr. and Mrs. L. J. Moody, and my relatives and friends, whose valuable support and encouragement contributed significantly to the completion of this study.

PAGE 4

TABLE OF CONTENTS Page ACKNOWLEDGMENTS ii LIST OF TABLES vi ABSTRACT ..... vii CHAPTER I INTRODUCTION / 1 The Problem Statement 2 Purpose of the Study ..... 3 Background of the Study 3 Definitions . 7 Assumptions, Limitations, and Delimitations . 8 II A SYSTEMS APPROACH TO EVALUATION 9 Underlying Concepts and Values of Validation Examinations 12 Multidimensional Approaches to Evaluation . . 15 Selection of Evaluation Approaches 20 The Cognitive Model 22 The Clinical Model 24 III INITIAL TESTING OF THE COGNITIVE MODEL .... 28 Sample Selection and Sample Studied 28 Hypotheses 30 Methodology . 31 Item Analysis 34 Data Presentation and Analyses 38 Conclusions 53 IV EVALUATING THE CLINICAL MODEL 55 Recommendations for Future Research and Utilization 59 Summary 63 BIBLIOGRAPHY 55 / iv

PAGE 5

TABLE OF CONTENTS (Continued) APPENDIXES Page A Santa Fe Community College — Credit by Exam Policy 71 B The Models — Obtaining Information 72 C RS-101 Introduction to Respiratory Therapy . . 73 RS-121 Medical Gas Therapy 74 RS-122 Humidity Therapy 75 RS-123 Intermittent Positive Pressure Therapy 76 RS-141 Respiratory Therapy Pharmacology ... 77 RS-151 Cardiopulmonary Resuscitation 78 RS-250 Cardiopulmonary Anatomy and Physiology 79 D Descriptive Data of RTVE Scores 80 Frequency Distribution of RTVE Scores 81 BIOGRAPHICAL SKETCH 82 V

PAGE 6

LIST OF TABLES Table Page 1 Clinical Performance Areas and Evaluation Mechanisms 26 2 Distribution of Test Items 32 3 Descriptive Statistics of Examinees' Total Scores on the RTVE 35 4 Descriptive Data and Total Scores of Examinees on the RTVE by Groups 39 5 Scattergram Depicting Correlation Between FTGAT and RTVE Scores 40 6 Analysis of Group Performance on the Total RTVE 42 7 Analysis of Group Performance on Section I — Introduction to Respiratory Therapy 43 8 Analysis of Group Performance on Section II — Medical Gas Therapy 44 9 Analysis of Group Performance on Section III — Humidity Therapy 45 10 Analysis of Group Performance on Section IV — Intermittent Positive Pressure Breathing ... 46 11 Analysis of Group Performance on Section V — Respiratory Therapy Pharmacology 47 12 Analysis of Group Performance on Section VI — Cardiopulmonary Resuscitation 48 13 Analysis of Group Performance on Section VII— Cardiopulmonary Anatomy and Physiology .... 49 14 Courses Passed by Group Members 52 VI

PAGE 7

Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy RESPIRATORY THERAPY VALIDATION EXAMINATIONS: A COMMUNITY COLLEGE MODEL By Linda Elizabeth Moody March 1977 Chairman: Margaret K. Morgan Major Department: Curriculum and Instruction Formal testing procedures that can be employed to assess proficiency of health workers are long overdue. This study developed a prototype to validate the competency of respiratory therapy personnel who wish to receive academic credit for knowledge gained through experience. Projected manpower needs for respiratory therapy established the purpose of the study: to develop diagnostic testing procedures that could be used to (1) grant academic credit and advanced placement and (2) prescribe the subsequent coursework required of candidates who take the national respiratory therapy examination to become registered. The use of validation examinations (equivalency and proficiency examinations) will provide career opportunities for those personnel (70% of the total respiratory therapy work force) who might otherwise be disqualified from working within the field because they have not been registered. A systems approach was used to develop validation examinations for seven courses offered in the first year of the respiratory therapy program at Santa Fe Community College, Gainesville, Florida. Objectives from the seven courses vii

PAGE 8

formed the basis for the content of the examinations, to assure content validity. Two models were developed that comprised multidimensional approaches to evaluate problem-solving ability and interpersonal and manipulative skills — the cognitive model and the clinical model. The cognitive model V7as a three and one-half hour examination consisting of 210 multiple-choice items that tested for memory, discrimination, evaluation, and problem-solving skills. A candidate had to score satisfactorily on each section of the cognitive examination to qualify to take the clinical examination. Nineteen subjects participated in the initial testing of the cognitive model that compared performances of three groups: Group I (five students who had completed the seven courses and had had respiratory therapy experience) , Group II (eight students who had completed the seven courses but had had no respiratory therapy experience) , and Group III (six respiratory therapy personnel with experience but no course work) . Item analysis of the written validation examination revealed that 88% of the test items had adequate discrimination and difficulty indexes. The reliability of the 210-item, multiplechoice examination, using Kuder-Richardson ' s formula 20, was sufficiently high (.88); the examination possessed content validity. Twenty-six items were revised for use in subsequent testing; none of the test items was of such poor quality to require deletion. Nonparametric analysis of variance, using the KruskalWallis procedure, revealed significant differences in performance among groups (£ < .05) on the total examination and viii

PAGE 9

four of the separate, course examinations. A high correlation (r= ,8318) was found between scores on the Florida Twelfth Grade Achievement Test and the total respiratory therapy validation examination. Procedures were proposed for assisting applicants to improve their test-taking skills. The clinical model comprised several evaluation approaches (clinical simulations, oral examinations, and role playing) that were designed to measure predefined interpersonal, psycho motor, and problem-solving skills. Role-playing examinations were videotaped for faculty review to obtain inter-rater reliability. Subsequent testing was advised with the clinical model to assess the reliability of the evaluation instruments used. Development of validation examinations for courses offered during the second year of the respiratory therapy program at Santa Fe Community College was recommended. Both models may be employed for summative evaluation of generic students in the respiratory therapy program. Students achievement on the validation examinations may be later compared with their performance on the national registry examination to provide follow up and accountability. Use of the testing models in two-year respiratory therapy programs would not only make curricula more accessible to the work force but would increase the number of qualified respiratory therapists. The study carries implications for all educators concerned with upgrading health care delivery. ix

PAGE 10

CHAPTER I INTRODUCTION More than 40,000 respiratory therapy personnel were available in 1976 to fulfill national manpower needs. But of these 40,000 only 10,500 (267o) have been certified or registered to practice in the field of respiratory therapy {Occupational Outlook Handbook, 1976). A survey (Sanderson, 1976) revealed that Alachua and Bradford counties in Florida had 1,435 hospital beds and 92 respiratory therapy personnel. Only 6 of the 92 practicing respiratory therapists were registered (Sanderson, 1976) . National statistics revealed that more than 607o of respiratory therapy personnel had inadequate education and training to prepare them to qualify for and pass national licensing or certifying examinations (Youtsey, 1975). Hospital-based training has been ineffective for preparing respiratory therapists for an occupation that demanded complex intellectual and psychomotor skills. Respiratory therapy has been the only allied health profession that has not required licensure or certification in order to practice within the field. McAleer (1975) expressed concern that many capable technicians would never have the opportunity to become 1

PAGE 11

2 certified because one year of full-time schooling was inaccessible or impossible. The American Association of Respiratory Therapy (AART) recognized the need for registration and certification in order to maintain standards of care; therefore, the AART will soon require all practicing respiratory therapy personnel to be registered or certified. Although many respiratory therapy programs have espoused the use of validation examinations, few, if any, have developed a flexible curriculum that provides formal evaluation procedures to grant advanced standing. The use of validation examinations would assist many qualified respiratory therapy personnel in obtaining the registration that will soon be required by the AART. The Problem Statement Diagnostic testing procedures were needed to evaluate previously acquired knowledge and experience of hospitaltrained respiratory therapypersonnel so that (1) academic credit and advanced placement could be granted for extant skills, and (2) formal instruction and clinical experiences prescribed to qualify candidates to take the registration examination offered by the National Board of Respiratory Therapy (NBRT) .

PAGE 12

3 Purpose of the Study The purpose of the study v/as to develop proficiency and equivalency examinations (validation examinations) that would be used for granting advanced placement to informally trained respiratory therapy personnel applying to the Santa Fe Community College Respiratory Therapy Program." The study was concerned with five major objectives: 1. Identification of types of examinations that are appropriate for each respiratory therapy course under study. 2. Development of cognitive examinations for the seven respiratory therapy courses to be used for validation examination. 3. Initial testing of the cognitive examinations with a group of students who have completed the seven respiratory therapy courses and a group of respiratory therapy workers who have had no formal coursework. Data analysis including descriptive statistics and analysis of variance. 4. Proposal of methods of affective and psychomotor examinations that may be used for validation examination of the courses under study. 5. Prescription of methods of evaluation and accountability for all advanced-placement students. Background of the Study Respiratory therapy, a relatively young occupation that emerged in the mid-1940s, grew out of rapid technological Support for the study was received from a Staff Program and Development Grant funded by Santa Fe Community College Gainesville, Florida, Project No. 122370

PAGE 13

4 advances in medicine and surgery that required skilled personnel who could work with respiratory ventilators (Whitacre, 1972) . The need for hospital staff who could manage complex ventilatory care became acute. To counteract the shortage of skilled staff, most hospitals hired persons (many without previous medical education or experience) to be trained on the job by physicians. Respiratory therapy personnel, formerly referred to as inhalation therapists, treat patients with cardiorespiratory problems. Treatment may range from giving assistance to persons with acute asthma to rendering emergency care in cases of drowning, heart failure, shock or other disorders that interfere with breathing. Respiratory therapy workers may be the first ones summoned during crises j thus, the role requires a high level of responsibility and skill {Occupational Outlook Handbook, 1976) . The advent of complex mechanical ventilators in the 1950s created a new type of health care unit called "intensive care" that demanded specially trained physicians, nurses, and respiratory therapists. As clinical skills increased in number and complexity, respiratory therapists needed a broader theoretical base in the sciences to provide an understanding of equipment and job functions charged to them. During the ensuing years, hospital-based training proved to be an ineffective method for educating personnel to adequately perform the skills required of a registered

PAGE 14

5 respiratory therapist (Youtsey, 1975). Physicians have been responsible for initiating curricular developments and training programs for respiratory therapists. The American Registry of Inhalation Therapy (ARIT) was founded in 1960 and with support from the American Medical Association (AMA) pilot examinations for registration began in 1961 (Whitacre, 1972). Basically, three levels of workers have performed within the field of respiratory therapy: therapists, technicians, and assistants. Respiratory therapists have a certificate of graduation from an AMA-approved training program, sixty-two semester hours of college credit, and one year of clinical experience. Respiratory therapists would be eligible to apply for the registration examination sponsored by the National Board for Respiratory Therapy (NBRT) . The registry examination has comprised two tests, a v/ritten and an oral. Persons who have completed an AMA-approved technician training program and have one year of experience in respiratory therapy can apply to the NBRT for examination for the Certified Respiratory Therapy Technician (CRTT) credential. The CRTT examination has been less comprehensive than the registry examination and consisted of a v/ritten test only. Requirements for respiratory therapy assistants have been varied, according to requirements of the local hospital director; some training programs required a high school diploma or previous hospital work. Hospital-based training was made available for some respiratory assistants. No

PAGE 15

6 licensure or certification has been required for respiratory therapy assistants {Ocaupatioyial Outlook Handbook, 1976). Since 1975, employment of respiratory therapy workers has been expected to increase faster than the average for all occupations . Respiratory therapy was one of the fastest growing allied health professions: Manpower needs will continue to spiral. Owing to new uses for respiratory therapy, increased acceptance of its use, and the growth in health services in general, many specialists in respiratory therapy will be hired to release nurses and other personnel from respiratory work to return to their primary duties. Those with advanced training in respiratory therapy will be in demand to fill teaching and supervisory positions. (Occupational Outlook Handbook, 1976 , p. 469) Many respiratory therapists have favored providing ways for respiratory therapy assistants and technicians to move up the career ladder to help fulfill national manpower needs. Youtsey proposed Mechanisms that deserve the most serious consideration are proficiency and equivalency examinations for ad^ vanced standing in approved respiratory therapist programs. (1975, p. 1050) As of 1976, no respiratory therapy programs in the United States have implemented a formal program for granting advanced placement, but several programs have expressed the intent to develop validation examinations in the near future (Wilson, 1976). The NBRT has strongly encouraged programs to employ equivalency examinations so that more personnel may become registered.

PAGE 16

7 Projected manpower needs within the field of respiratory therapy justified development of mechanisms to increase career mobility for all personnel. The development and use of validation examinations may provide career advancement for many personnel who might other\^ise be eventually disqualified from working within the field because they have not been certified or registered. Validation examinations may also provide a service to health care consumers by improving the quality of care received during hospitalization. If the proposed validation examinations at Santa Fe Community College prove to be effective mechanisms for assisting persons to become registered respiratory therapists, then the testing models may be adapted for use throughout respiratory therapy programs in the United States. Definitions Advanced placement (standing) the granting of academic credit, for experience and knowledge gained informally, to candidates who pass exemption (validation) examinations . Proficiency examination an evaluation method that tests for competence derived from training and practice in clinical skills; it also tests for clinical aptitude and problem-solving ability (Wilson, 1976). Equivalency examination an evaluation procedure that compares theoretical knowledge with that offered by the formal program (Wilson, 1976). Validat ion examination evaluation approaches that consist of a combined proficiency and equivalency examination. Generic student a student enrolled in the respiratory therapy program at Santa Fe Community College, who has not been granted advanced placement.

PAGE 17

8 Assumptions, Limitations, and Delimitations A major assumption of this study was that valid and reliable methods could be developed to assess cognitive, affective, and psychomotor skills of respiratory therapists. Another assumption was that applicants who score as well as generic students on the validation examinations have attained equivalent knowledge as compared to students who have completed the respective coursev/ork in the respiratory therapy program at Santa Fe Community College. A major limitation of the study was the inclusion of only one testing session, while recognizing that several testing sessions with validation examinations would be required to produce cognitive and clinical evaluation models of acceptable validity and reliability. Since the validation examinations were based on specific course objectives and the Respiratory Therapy Task Analysis (1975) , the examinations were delimited for use at Santa Fe Community College but could be adapted for similar programs nationwide. Results from initial testing of the cognitive model were not generalizable beyond the samples studied.

PAGE 18

CHAPTER II A SYSTEMS APPROACH TO EVALUATION A systematic approach to curriculum development will facilitate the development and ,utilization of validation examinations. The process of curriculum planning is a djniamic one that includes data collection, prescription, treatment, and evaluation. Saylor and Alexander defined curriculum as "a plan for providing sets of learning opportunities to achieve broad goals and specific objectives for an identifiable population served by a single school center" (1974, p. 6). Since the primary purpose of the study was to develop evaluation procedures for granting advanced placement, the entire curriculum plan at Santa Fe Community College required appraisal. Evaluation is an integral part of curriculum design and curriculum planning. Stuff lebeam and other educators (1971, p. XXV) defined evaluation as "the process of delineating, obtaining, and providing useful information for judging decision alternatives." Evaluation encompasses but surpasses the meanings of the terms "test" and "measurement" (Mehrens and Lehmann, 1973). Mehrens and Lehmann explained the attributes of evaluation : 9

PAGE 19

10 1. provides knoxvledge concerning the students' entry behaviors ; 2. assists in setting, refining, and clarifying realistic goals for students; 3. determines the degree to which objectives have been achieved; 4. assists in determining, evaluating, and refining instructional techniques; 5. communicates goals of the teacher and increases motivation ; 6. provides feedback to students that identifies their strengths and weaknesses; and, 7. aids in the administrative decisions of selection, classification, and placement. (1973, p. 15) Evaluation measures predefined characteristics or properties of people and should not be confused with evaluating a person's worth. Evaluation attempts to quantify predefined qualities. Therefore, educators must be aware of the inherent weaknesses in the evaluative process and make concerted efforts to eliminate deficiencies. Defining educational goals in behavioral terms is one way to make the evaluation process more equitable. Evaluation presumes prespecified goals or objectives. The systems approach to curriculum design offers an orderly, inclusive process for identifying goals and objectives. A systems approach to curriculum design involves tv/elve stages, according to Gagne and Briggs (1974, p. 213): Analysis and identification of needs Definition of goals and objectives Identification of alternative vzays to meet needs Design of system components Analysis of resources required, resources available, and constraints Action to remove or modify constraints Selection and development of instructional materials Design of student assessment procedures Field testing-formative evaluation and teacher training 1. 2. 3. 4. 5. 6. 7. 8. 9.

PAGE 20

11 10. Adjustments, revisions and further evaluation 11. Summative evaluation 12. Operational installation Not all systems design theorists follow the outline proposed by Gagne and Briggs but all support the idea that an ongoing, systematic effort is made to define learner needs, learner objectives, evaluate learner behavior, and revise objectives and instruction when indicated. An effective way to design a curriculum is to work backwards from the outcomes it is expected to have. Educational goals are statements of the outcomes of education; they must be identified before instruction and evaluation can be intelligently designed (Gagne and Briggs, 1974). Valid and reliable evaluation methods can be developed after the curriculum objectives for each course have been stated in behavioral terms and the three learning domains considered (cognitive, affective, and psychomotor). Scannell and Tracy supported this approach: Stating in advance explicit objectives for instruction will improve the quality of evaluation by making it reflect more accurately the teacher's true instructional intentions. (1975, p. 28) Controversy may be sparked when development of affective objectives is discussed. Critics argue that writing affective objectives in behavioral terms becomes a trivial task and masks the real learner behavior that is desired. Thus, some educators completely abandon the complex task of identifying values students should possess as a result of

PAGE 21

12 instruction. Radocy (1974) asserted that quantification of affective behavior was not a problem of measurement theory, but a problem of human negotiation. If identified values are important for learners to possess, the evaluator must state what is acceptable evidence of a desired condition. Failure to consider the affective domain results in an instructional program that is often labeled "mechanistic" by students; this may be the reason systems design is thought to be less humanistic. However, the curriculum planner has the option of building in the humanistic elements in any design that is selected; this seems especially important to include in any health related program. Before validation examinations are considered in any program, a sound educational curriculum is required. Appraisal of general program and specific course objectives at Santa Fe Community College revealed an educational readiness to undertake the development of validation examinations. Behavioral objectives from the seven courses under study and the Respiratory Therapy Task Analysis (1975) provided the structure, content, and formats for the validation examination. Underlying Concepts and Values of Validation Examinations Any program that adopts the use of validation examinations supports the belief that learning is not confined to the classroom but occurs through meaningful experiences that

PAGE 22

13 involve learners actively; this conmitment was shared by the respiratory therapy faculty at Santa Fe Community College. Many persons, through personal experiences or v7ork situations, develop attributes and competencies similar to those developed by students in academic programs. People deserve an opportunity to gain academic credit for their expertise without repeating educational experiences designed to develop skills when those skills are already possessed. The use of validation examinations was founded upon the American educational belief that people should be encouraged and assisted to approach their potential. Wilson (1976) defined equivalency as . . . the comprehensive evaluation of knowledge and skill competencies and the emotional attributes developed through alternate experience to determine if those thus gained are equivalent to the competencies and attributes developed through the formal program of the educational institution. (p. 232) Desired learner attributes and behaviors must be identified for each course within the curriculum prior to the development of validation examinations. Otherwise, no standards exist with which to compare the expertise submitted by the candidate. The concept of equivalency evaluation or validation examination implies that competencies and attributes of like value and significance will be honored. Validation examination is a summative type evaluation that measures progress achieved over a longer period of time and supplies information about

PAGE 23

14 subsequent instruction and learning needed by the student (Wilson, 1976). The validation process is diagnostic and prescriptive; it reveals how well the candidate meets the qualifications of a practitioner within the selected field. Faculty who adopt validation examinations must show that generic students in their program can pass the examinations; it would be unfair to judge applicants by standards that generic students were not able to achieve. A flexible curriculum that allows entry at most course levels is essential if validation examinations are implemented. To require applicants to take courses unnecessarily would decrease motivation and defeat the purpose of the program. Enthusiastic proponents of exemption examinations express the idea that all students should be assessed for levels of knowledge and then placed in appropriate courses. National use of the College-Level Examination Program (CLEP) is an example of educational efforts to consider individual abilities and experiences. Development of validation examinations for use at Santa Fe Community College will serve the express purpose of providing a mechanism for respiratory therapy personnel to qualify to take the NBRT registration examination. Thus, it will not only offer career opportunities but provide a service to health care consumers. Faculty must be able to express their ideas and beliefs freely to one another regarding validation examinations.

PAGE 24

15 Consensus must be reached as to how the examinations will be developed and implemented and what kind of grading system will be used for candidates who pass the validation examinations . Wilson (1974) surveyed 150 health practitioner programs in the United States and reported that 28 offered some type of informal equivalency testing. Wilson also found that most faculty viewed equivalency testing as traditional credit by examination. If faculty have this misconception, they may be reluctant to use validation examinations from fear that many students will be able to exempt all of their courses. Faculty of health programs, who accept the use of validation examinations, must be wholly committed to the development of capable practitioners who possess the minimum basic competencies and attributes required for proficient practice; the validation examinations must be designed to test for basic competencies and attributes. Thus, more than one testing approach is required. Multidimensional Approaches to Evaluation The concepts underlying the use of validation examinations demanded that more than one testing approach be used to assess the cognitive, affective, and psychomotor skills of candidates applying for advanced standing to the respiratory therapy program at Santa Fe Community College.

PAGE 25

16 Prior to planning evaluation approaches, an analysis of objectives for each course under study should be undertaken to determine what types of skills the learner is to perform: manual, verbal, memory, discrimination, or evaluation. The next step will involve identification of appropriate evaluar tive procedures for the respective skills. Validation examination may include measurement proce-. dures that have not been used extensively in academic programs. Creative and innovative approaches need to be explored especially in the realm of clinical evaluation. Wilson (1976) suggested that media-supported evaluation and simulations be developed for evaluating competencies. Only recently have simulations been seriously consid;. ered in academic programs. However, the use of simulations dates back to ancient times. Chess is the oldest form of war game and war games are the oldest type of simulations (Tansey, 1971). In the ideal simulation, the participant assimilates the information or material available to him in order that he may reach the goal set for him. Simulation makes it necessary to make sure of the facts, to collect, evaluate, and analyze the information. Then, there is an obligation to see the whole of the problem, or to diagnose the situation as it appears. Reflection, interpretation, and discussion are needed to crystallize the simulation (Tansey, 1971). Simulation has many possibilities for use in evaluation of people in the health field because it is a useful device

PAGE 26

17 for testing decision-making skills. Simulations can examine the large and complex pattern of human relationships and abstract portions that need investigation or that are considered important (Tansey, 1971, p. 29). Taylor and Walford cited the primary objectives of simulation: 1. presenting a simplified abstraction of the bare essentials to a situation free from trivia and irrelevance ; 2. concentrating on making explicit, essential relationships and the fundamental interplay between key roles; 3. unfolding time at a quicker rate than normal so that the implications of action in a dynamic situation can be clearly and repeatedly felt; 4. allowing students to "sit in the hot seat''' and feel the direct impact of the consequences of decision making; and, 5. offering opportunities for collaborative learning on self-directed lines. (Taylor and Walford 1972, pp. 48-49) A major type of simulation is role playing, which is the simplest form, in that it has the least formal structure. Role playing relies on the spontaneous interaction of participants when placed in a hypothetical situation. Role playing was originally used in the 1930s as a means to study the psychological behavior of small groups (Tansey, 1971). During the 1940s, role playing was used in drama as a liberating and self-educating activity for pupils in school; the influence of role playing had more affective than cognitive impact, particularly in the free-form situations in drama or English lessons. "Theatrein-Education" projects

PAGE 27

18 that were sponsored by local repertory theatres became popular in the 1950s and 1960s (Taylor and Walford) . In role playing, the players accept assigned identi• ties and act or react appropriately. The essential core of the activity is understanding the situation of the other person (s) and responding in kind. The player is given the opportunity to experience what is at stake. The presumption is that through such participation players gain a greater understanding of their roles and relations (Taylor and Walford) A requirement of role playing is that the players must be able to assume the assigned roles. A simulation is ineffective if the participant is detached from the activity because involvement is the element that makes role playing an effective instructional and evaluation method. Role playing has been used to help students in the health professions gain empathy into the helper-client relationships. Crisis situations that cannot be employed or participated in by students in clinical settings can be simulated and roleplayed if the expectations are well defined for the players and the situation is designed to represent a real-life situation. Spontaneous reactions of the player or examinee may serve as a guide to self-understanding and represent how that person may have acted in the true situation; it may serve as an effective evaluation procedure.

PAGE 28

19 Simulations provide a degree of stress for the players but whether it is equivalent to the stress produced by the real-life situation in a hospital setting continues to be moot. The most frequently used simulation in the health professions is cardiopulmonary resuscitation: a procedure requiring high levels of cognitive, affective, and psychomotor skills that must be performed correctly, within a few seconds. A life-like mannequin was developed to provide feedback to the resuscitator , indicating whether the procedure was done correctly. The model has proved successful for teaching and evaluating this complex .skill required of health personnel. The use of videotape to record role playing or clinical simulations is useful for evaluation and instructional purposes. Players and teachers gain a better understanding of their behavior; they can analyze mistakes and successes to respond more appropriately. Planning and development time, number of personnel required, and cost are the primary disadvantages of using simulations and videotape equipment. Tansey discussed the importance of designing the elements of the simulation: The designer of the model must make certain value judgments. Ke must decide what are the essential processes and what processes are secondary. In other words he must obviously decide what has to be left out. His aim, at this stage, is to reduce the

PAGE 29

20 complexity of a real life situation, to simplify it in order that its essence may be studied beneficially. His dilemma is that if he puts too much of the actual situation in he may so complicate the simulation as to make it a poor vehicle for instruction. On the other hand, if he leaves too much out he may produce a model that does not accurately represent the system he wishes to present. He must also be aware of the danger of personal interest and the tendency toward bias and distortion. (pp. 7-8) Perhaps the most important steps of planning a simulation are first identifying the behaviors that are to be exhibited, then providing the examinee with enough data and support to exhibit the desired behaviors. Selection of Evaluation Approaches The researcher met with the respiratory therapy faculty at Santa Fe Community College to discuss possible evaluation approaches. The following questions were presented to gain needed faculty commitments: 1. VJhat objectives from each course will be tested? 2. To what kind of testing does each objective lend itself? 3. What objectives do faculty expect all students to perform at an acceptable level? 4. What types of affective, cognitive, and psychomotor evaluations are presently used for each course? 5. How, where, and by whom will the examinations be administered?

PAGE 30

21 6. Should the examinations be administered on the same day or separate days: a session for cognitive evaluation and one for clinical evaluation? 7. What types of audiovisual equipment, clinical facilities, and respiratory therapy equipment are available to use for clinical evaluation? 8. How will the validation program interface with the credit-by-examination policy at Santa Fe Community College? Several planning and think-tank sessions with the respi atory therapy faculty provided answers to many of the proposed questions. Faculty agreed that, considering the types of skills that were to be evaluated, the resources, and time available, two evaluation models would be developed: the cognitive model and the clinical model. The models would include several evaluation approaches to accommodate the var ious cognitive and performance styles of candidates. Enthusiastic administrative support was received from Santa Fe Community College to assist in implementing the val idation program; financial support v;as granted to applicants taking the validation examination. Students are usually required to pay $15 per course for credit by examination (Appendix A) . Object ives from each of the seven courses were reviewed and categorized into the cognitive model or the clinical

PAGE 31

22 model for testing. The content of both models was determined by the theoretical knowledge required to practice respiratory therapy proficiently and the affective and psychomotor skills thatv/ere essential for all respiratory therapy students to perform after completing the seven courses under study (Appendix B) . The Cognitive Model The Respiratoi'y Therapy Task Analy sis (1975) and objectives from the seven courses were used to prepare Tables of Specifications for each course (Appendix C) . The specification tables were distributed to the four respiratory therapy faculty who rated the contenttopics of each course. The mean weights assigned by the faculty raters were used in developing the test items and weights for each content area. Meh rens and Lehmann (1973) discussed the importance of preparing Tables of Specifications : The purpose ... is to define as clearly as possible the scope and emphasis of the test, and to relate the objectives to the content. The test must be a valid measure of the pupil's knowledge, skills, and other attributes that the teacher sought specifically to teach. By ensuring that the test adequately covers the content and is directly related to the objectives, the teacher has satisfied the most important criterion of the test — content validity. (p. 181) The next step was to decide what type of testing format to use in the cognitive model. Because of the nature of the objectives being tested and the length of the material to be covered, the multiple-choice format was selected.

PAGE 32

23 If developed and used judiciously, the multiple-choice format can be a valid and reliable evaluation test. The format allows versatility for testing different skills: recall, recognition, discrimination, evaluation, application, or reflection. Unfortunately, many evaluators devise multiple-choice examinations that only test memory skills. Mehrens and Lehmann (1973) discussed the major advantages and limitations of multiple-choice examinations. The follow ing advantages were cited: 1. Multiple-choice questions can measure factual recall but also measure reasoning ability, judgment, and problem-solving. 2. The tests can be scored quickly and accurately. 3. They are relatively efficient in terms of the number of questions that can be asked in a prescribed time, and the space needed to present the questions. 4. Compared to true-false items, multiple-choice questions have a relatively small susceptibility to score variations due to guessing. 5. Multiple-choice items provide diagnostic information and greater reliability than true-false items. 6. Students prefer multiple-choice items because they are less ambiguous than true-false questions. 7. Of all the selectiontype objective items, the multiple-choice item is most free from response sets. (p. 280) Critics of multiple-choice examinations argue that the testing format leads to the asking of trivial, ambiguous questions. However, triviality and ambiguity are not inherent in the format but interjected by the item writer. The recognized limitations of multiple-choice items were as follows:

PAGE 33

24 1. They are difficult to construct.. Teachers cannot always think of plausible sounding distracters. 2. There may be a tendency to write multiple-choice items demanding only factual recall. 3. Multiple-choice items require the most time for students to respond, especially when very fine discriminations have to be made. 4. Test-wise students perform better than nontest-wise students. (Mehrens and Lehmann, 1973, p. 281) The final form of the examination consisted of 210 multiple-choice items. All examinees should be able to complete the examination in three and one-half hours, allowing 60 seconds responsetime per item (Noll and Scannell, 1972). For all test items, four distracters were used. All of the responses were alphabetized or placed in ascending numerical order, to avoid biased placement of the correct responses. The researcher directed efforts toward constructing test items that measured the examinee's ability to discriminate, make judgments, solve problems, and evaluate. Except for information and facts that respiratory therapists needed to know, factual-type questions were avoided. The examination was reviewed by three judges for clarity, readability, and accuracy of correct responses and revised prior to the initial testing. The Clinical Model The researcher designed the clinical evaluation to measure several skills: clinical application of knowledge, ability to assemble, operate, and maintain selected respiratory therapy apparatus, verbal expression, interpersonal skills, and problemsolving ability.

PAGE 34

25 The Respiratory Therapy Task Analysis (1975) and objectives for the first-year level courses were reviewed for the purpose of selecting content and objectives representative of the skills that students were expected to demonstrate after completion of the seven courses. The respiratory therapy faculty were presented with a set of skills for each of the seven courses and asked to designate the skills that were essential for respiratory therapists to know and perform correctly. Faculty were also asked to select the skills that the examinee must perform without error. The clinical examination included various testing formats: oral expression, role playing, and demonstration of psychomotor skills. Before the clinical evaluation could be finalized, several faculty planning sessions were held to accomplish the following tasks: 1. Identify specific learner behaviors that apply to the testing situations for each course 2. Establish performance standards 3. Decide how each testing situation is to be implemented. Irby and Dohner (1976) discussed the developmental phases of clinical performance assessment:

PAGE 35

26 1. Development of the management plan, which includes the rationale, goals, activities, and resources needed . 2. Instrument development, involves defining tasks and performance standards, as well as creating and field testing instruments. 3. Implementation, which consists of tasks that make the system operational: training faculty to objectively and reliably observe student performance and provide effective feedback; establishing a routine data collection and analysis process; determining grading procedures; and, reporting the results of student achievement. (p. 208) The evaluation mechanisms were employed to assess clinical performance in four areas (Table 1) . Table 1 linical Performance Areas and Evaluation Mechanisms Performance Area Evaluation Mechanisms Knowledge Oral examinations Clinical simulations Observations Technical Skills Clinical simulations Observations Interpersonal Skills Role playing" Observations Habits and Attitudes Role playing Clinical simulations Observations Clinical evaluation: Alternatives for health related educators, by D.M. Irby and M.K. Morgan, 1974, p. 2. Copyrighted 1976 by Margaret K Morgan. Cited by permission. ole-playing simulations were videotaped fo raters . r review

PAGE 36

27 The clinical evaluation model consisted of an agenda of behavioral skills to use when testing for the six courses listed below: RS 123 and P^.S 141 were combined into one examination since the skills of both courses are performed concurrently in the hospital situation. Faculty examiners were oriented to the checklist of behaviors and equipment and personnel schedules that were developed for administering the clinical examination. The laboratory facilities at the Respiratory Therapy Department at Santa Fe Community College were reviewed and found to be adequately equipped and designed for implementing the clinical evaluation. Four clinical situations were designed to test for interpersonal skills via role playing. All the role-playing situations were designed to be videotaped for rating by two or more faculty members. Volunteer actors from Santa Fe Community College would be provided with guidelines for each role-playing situation. RS 101 RS 121 RS 122 RS 123 RS 141 RS 151 Introduction to Respiratory Therapy Medical Gas Therapy Humidity Therapy Intermittent Positive Pressure Breathing Respiratory Therapy Pharmacology Cardiopulmonary Resuscitation

PAGE 37

CHAPTER III INITIAL TESTING OF THE COGNITIVE MODEL An item analysis of the cognitive model included the following indexes: item difficulty, item discrimination,' and test reliability. Initial testing was conducted to determine major strengths and weaknesses of the examination so that revisions could be made prior to using the tests with subsequent groups. The computing facilities at the Office of Instructional Resources, University of Florida, were used to score the examinations and analyze the test items. Sample Selection and Sample Studied The decision was made to test the examination with three different groups. Group I, Santa Fe Community College students, had completed all Level I Courses, the seven courses under study, and had previous respiratory therapy experience. Group II, Santa Fe Community College students, had completed Level I Courses but had no previous respiratory therapy experience. Group III was personnel who had clinical experience in respiratory therapy but had no formal respiratory therapy coursework. The rationale for using the three particular groups was that CD a performance comparison was needed 28

PAGE 38

29 between students who had completed the seven courses and subjects without any Level I coursework to determine the equibility of the examination, recognizing that it would be unfair to judge candidates by standards that generic students might not attain, and (2) the vnriter was interested in performance differences among groups with coursework, experience in the field, and combined coursework and experience in the field. The investigator assumed that no major differences in general intelligence between groups would exist; however, students in the program would be expected to perform better because they had completed the coursework and might be more test-wise than Group III. The method of sample selection was purposive. Although this method was not as effective as random sampling, the technique was justified because of the purposes of the initial testing (Kerlinger, 1973). Nineteen subjects participated in the testing session of the cognitive model. The sample studied consisted of 13 students in the Respiratory Therapy Program at Santa Fe Community College: 5 students were in Group I (experience and Level I coursework) and 8 students were in Group II (Level L. .. coursework only). Group III comprised 6 subjects who had no Level I coursework and were currently v/orking as respiratory therapy assistants in Alachua County. The subjects in Group III were volunteers who responded to a letter inviting

PAGE 39

30 all respiratory therapy personnel in Alachua and Bradford Counties in Florida to participate in the testing session. Initially, 14 respiratory therapy personnel applied to take the examination. After reviewing the objectives from, the seven courses under study, 8 respiratory therapy personnel withdrew because they reported that their experiences and knowledge levels were inadequate to prepare them to pass any portions of the cognitive examination. Hypotheses The null and research hypotheses for testing the cognitive model were proposed. 1. H^: No difference in mean scores on the total respiratory therapy validation examination (RTVE) will be found between the three groups. ^a" least one of the three groups differs from the others with respect to mean scores on the total RTVE. 2. H^: No difference in mean scores on Section I of the RTVE will be found betv/een the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on Section I of the RTVE. 3. H^: No difference in mean scores on Section II of the RTVE will be found between the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on Section II of the RTVE. 4. H^: No difference in mean scores on Section III of the RTVE will be found betv/een the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on Section III of the RTVE.

PAGE 40

31 5. H^: No difference in mean scores on Section IV of the RTVE will be found between the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on Section IV of the RTVE. 6. H^: No difference in mean scores on Section V of the RTVE will be found between the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on Section V of the RTVE. 7. H^: No difference in mean scores on Section VI of the RTVE will be found between the three groups. At least one of the three groups differs from the others with respect to mean scores on Section VI of the RTVE. H : a H^: No difference in mean scores on Section VII of the. RTVE will be found between the three groups. At least one of the three groups differs from the others with respect to mean scores on Section VII of the RTVE. H : a The rejection region was established: reject the null hypotheses if H exceeds the tabulated value of chi square for £< .05 and 2 degrees of freedom, Methodology t The examination consisted of 210 multiple-choice items and was divided into seven sections to represent content for each of the seven courses. An examinee must score satisfactorily on a section to quality for the respective clinical examination. The rationale underlying this policy was a belief by respiratory therapy faculty that all respiratory

PAGE 41

32 therapists should be able to perform academically at the community college level, since higher level verbal and mathematical skills are required to practice respiratory therapy effectively. The examination items were distributed as displayed in Table 2. Table 2 Distribution of Test Items Number t Course Test Total Items Test RS 101 Introduction to Respiratory Therapy 26 12.38 RS 121 Medical Gas Therapy 26 12.38 RS 122 Humidity Therapy 25 11^91 RS 123 Intermittent Positive Pressure 25 11.91 Breathing RS 141 Respiratory Therapy Pharmacology 26 12.38 RS 151 Cardiopulmonary Resuscitation 30 14.28 RS 250 Cardiopulmonary Anatomy and Physiology 52 24.76 Total 210 100 RS 250 was assigned more weight for the written examination because the course content did not lend itself to clinical evaluation. For most five-response multiple-choice formats, examinees should be able to respond to an item in 60 seconds or less (Mehrens and Lehmann, 1973). The examination was not considered to be a test of speed. All examinees were allowed time to complete all test items. Projected completion time . for the examination was three and one-half hours. All items were given equal weight. Following

PAGE 42

33 recommended testing protocol (Mehrens and Lehmann , 1973), examinees were instructed to answer as many questions as possible and were informed they V70uld not be penalized for guess ing. A correction formula for guessing was not used. Names of the examinees were knovm only by the examiner; each examinee was assigned a number to reduce the threat for respiratory therapists who were i>7orking in Alachua or Bradford county. Examinees granted permission to code the following information on the response sheets for storage on computer tape and use in future analyses: social security number, • birth date, sex, number of years of education, number of years of respiratory therapy experience, group mem.bership (1, 2, or 3), and Florida Twelfth Grade Achievement Test (FTGAT) scores. The FTGAT scores were recorded on all individuals who completed high school in Florida in order to provide a common index of academic ability of the examinees. Subjects with high scores (400 or more) would be expected to be more test-wise (Goolsby, 1967) and perform better on the RTVE . ' " All students and respiratory therapy personnel that participated in the examination had access to all objectives of the seven courses under study. Respiratory therapy personnel were mailed copies of the objectives six weeks prior to the testing date. • "

PAGE 43

34 The examination was administered to 18 subjects at the same time, under the same testing conditions. One subject •was unable to attend the group testing but was administered the test later, under similar conditions. Times to complete the examination ranged from 1 hour and 40 minutes to 3 hours and 20 minutes; most examinees completed the test in 2 hours and 15 minutes . ' Item Analysis Using the optical scanner and computing facilities at the University of Florida, the examination data were analyzed by determining the following indexes: item-by-item response display, item difficulty, item discrimination, descriptive statistics, and Kuder-Richardson estimate of reliability (formula 20) . Although a larger sample was desirable but inaccessible, the data obtained revealed important trends and information .about the 210 examination-items and the 19 subjects who participated in the initial testing. Table 3 shows the range of scores, mean, median, mode, standard deviation, standard error, and reliability index for the total examination. The mean, median, and m.ode coincide (124), suggesting a normal distribution. The range (93-155) depicts adequate variance. Using the standard error of measurement (Sg), a person's true score on the Respiratory Therapy Validation Examination (RTVE) can be predicted to be

PAGE 44

35 within ± 1.96 (5.91) of the observed score, 95% of the time. The reliability index for the total examination is desirably high (.88). Although agreement is not universal, in general tests used in making important decisions about individuals should have reliability coefficients of .85 or greater (Noll and Scannell, 1972). Kuder-Richardson ' s formula 20 provides an estimate of internal consistency and also explains to what extent the observed variance is due to true-score variance (Mehrens and Lehmann , 1973). Table 3 Descriptive Statistics of Examinees' Total Scores on the RTVE Total number of examinees 19. 00 Total number of items on exam 210. ,00 Range of scores — High = 155. 00 Low = 93. 00 Highest possible score 210. 00 Mean raw score 124. 00 Median raw score 124. 00 Mode raw score 124. 00 Standard deviation (raw score) 17. 07 Standard error of measurement 5. 91 Kuder-Richardson' s Reliability Index (formula 20) 88 Even more important than test reliability, was validitydid the instrument measure what it was intended to measure? Because the 210 test items were based on specific course objectives and the Tables of Specifications (Appendix C) , the RTVE possessed content validity. "There is no commonly

PAGE 45

36 used numerical expression for content validity: It is determined by a thorough inspection of the items" (Mehrens and Lehmann, 1973, p. 124). Four respiratory therapy judges and one test construction consultant reviewed the examination and course objectives to verify the content validity of the cognitive model. Appendix D depicts descriptive data and frequency distribution of scores on the total RTVE . Ideally, samples larger than 30 should be used so that chances of approaching a normal distribution are increased (Noll and Scannell, 1972). Because of the small sample, the difficulty and discrimination indexes must be evaluated cautiously and viewed as contextual to the content of the test items and course objectives. Review of the item difficulty indexes revealed a wide range (.00 to 1.00), indicating that on 3 items, all students answered incorrectly and on 12 items, all examinees responded correctly. The investigator and the coordinator of the Respiratory Therapy Program reviewed the test items that were too easy (greater than .70) and too difficult (less than ,40) to determine whether the items should be revised or deleted. An ideal average difficulty index for a maximally discriminating test, using the five-response, multiple-choice format, is .40 to .70 (Mehrens and Lehmann, 1973). A total of 26 test items were revised by making minor changes in the stems, answers, or distracters to clarify ambiguous or misleading items. The problem cannot be resolved by examining the

PAGE 46

37 indexes alone. If all examinees responded correctly to objectives that should be mastered, then the items should be retained but examined carefully to improve the discrimination indexes. For most tests with samples of less than 30 examinees, a discrimination index of .20 is adequate (Noll and Scannell, 1972) to discern the high-performers from the low-performers . Items with negative discrimination indexes were reviewed and revised to improve the quality of the stems, answers, and distracters; these were, for the most part, the same 26 items that had undesirable difficulty indexes. A total o,f 50 test items had discrimination indexes less than .20. A larger sample would have yielded higher discrimination indexes. No further revisions were indicated until the examination had been tested with 60 or more students. None of the test items was deemed to be of such poor quality to require deletion. An important point to keep in mind when examining an item analysis is that the data obtained applies to the particular group that participated in the testing session and are not necessarily generalizable beyond the sample tested (Noll and Scannell, 1972).

PAGE 47

38 Data Presentation and Analyses Descriptive data and total scores of examinees on the RTVE by groups are displayed in Table 1. Fourteen males and five females participated in the testing. The mean age of examinees was 25.5 years. Subjects in Group III were, on the average, 3 years older than subjects in Group I and Group II. No notable differences were found in years of formal education. Four subjects in Group III had attended community or senior colleges in non-respiratory related fields. Subject 2, in Group III, had a master's degree in education and also had the greatest number of years of experience in respiratory therapy. Group III had a mean of 6.66 years experience in respiratory therapy as compared to a mean of 2.2 years for Group I. Examinees with experience and respiratory therapy coursework (Group I) scored highest on the RTVE and Group III (experience but no respiratory therapy coursework) obtained the lowest mean score on the RTVE. Subjects who had scores of 400 or greater on the FTGAT achieved the highest scores on the RTVE. The product-moment correlation between the 10 available FTGAT scores and respective total scores on the RTVE (Table 5) was high (r = .8138). The amount of variance in scores on the RTVE that could be explained by r' was 66% (r^ = .6622). The correlation between the two tests was not causal but indicated that persons who scored high on one of the variables would probably score high on the other variable (Hays, 1973).

PAGE 48

39 Table 4 Descriptive Data and Total Scores of Examinees on the RTVE by Groups Years of Years of RTVE FTGAT Group N Age Sex Education RT Experience Scores Scores I 1 24 M 13 3 155 459 2 22 M 14 2 149 486 3 30 M 14 1 139 --->'< i g ^ 22 F 13 1 136 411 5 26 F 14 4 128 (n p u — — iz_ ^''g.M 24.80 13.60 2.20 141.40 452 00 ox II ^ 0) CO C 1 23 M 14 2 22 F 13 3 31 M 15 4 22 M 13 5 27 M 13 6 20 F 13 7 23 F 14 8 29 M 13 M 24. 62 13 III c •H t-i c (U o a X w 1 28 M 14 2 35 M 16 3 23 M 13 4 24 M 12 5 23 M 13 6 31 M 14 M 27. 33 13 0 143 411 0 125 0 124 u ^ zz M 13 0 124 365 ^ ^1 M 13 0 118 0 118 329 / 23 F 14 0 116 359 8 29 M 13 _g 116 ) 0 123.00 366.00 6 145 12 113 7 109 375 5 107 2 98 373 8 93 175 6.66 110.83 307 Grand Mean 25.55 13.57 124.00 374.30 Graduated from non-Florida high school.

PAGE 49

40 Table 5 Scattergram Depicting Correlation Between FTGAT and RTVE Scores 500-450 400 350 FTGAT 300 250 200 150 100^^ 90 100 110 120 130 140 150 160 RTVE The probability that the product-moment correlation (r= .8318) between FTGAT and RTVE scores did not occur by chance is significant at p < .05, 8 df (Popham, 1967, p. 396) . Because the small sample size and unequal group sizes posed a threat of violating the assumptions of parametric analysis of variance, the Kruskal-Wallis test was used to analyze variance among groups (Hays, 1973).' The Kruskal and Wallis procedure is a nonparametric , one-way analysis of variance and can be effectively used for experimental and nonexperimental data (Kerlinger, 1973). Scores in each group are ranked, then the ranksum attached to each separate group is found. T. = the sum of ranks for group j and T is the

PAGE 50

41 sum of these rank suras. If the ranking was done correctly, then N(N+1) 2 (Hays, 1973, p. 783) . The formula used to test each hypothesis is E -4 -3(N+1) (Hays, 1973, p. 783) . The values of H were referred to the chi-square distribution with 2 degrees of freedom for testing the null hypotheses that all J score distributions were identical for the entire examination and the seven section examinations. From the chi-square distribution, the critical level for rejecting the null hypotheses at .05 and 2 degrees of freedom, was 5.99 (Hays, 1973, p. 887). Tables 6-13 display the group means, grand means, and H values for the total examination and the seven separate course examinations. Significant differences were found among the groups for the total examination (Table 7) and four of the section examinations (Tables 7, 8, 12, and 13).

PAGE 51

42 Table 6 Analysis of Group Performance on the Total RTVE Group I Group II Group III Coursework Coursework Experience and Only Only Experience Score Rank Score Rank Score Rank 155 1 143 4 145 3 149 2 125 8 113 15 139 5 124 9 .5 109 16 136 6 124 9 .5 107 17 128 7 118 11 .5 98 18 118 11 .5 93 19 116 13 .5 M 141.4 T. 21 J M 123 T. 81 J M 110.83 T. 88 J T? 441 J n=5 Tj 6_^61 n=8 T? = 7744 J * n=6 H = 9.4416, significant at 2 < .05, 2 df. Grand mean for all subjects on the RTVE = 124 (highest possible score 210) .

PAGE 52

43 Table 7 Analysis of Group Performance on Section I Introduction to R.espiratory Therapy Group I Group II Group III Coursev7ork Coursework Experience and Only • Only Experience Score Rank Score Rank Score Rank 24 2.5 26 1 22 7 22 7 24 2.5 19 14 2.2 7 23 4 18 16 20 11.5 22 .7 17 17 19 14 22 7 16 18 21 10 .14 19 20 11.5 19 14 M 21.4 T. 42 M 22.12 T. 57 M 17.66 T. 91 J J J T? 1764 J ' T? J 3^49 T? 8,281 n=5 n =8 n=6 K = = 7.5501, significant at E< .05, 2 df. Grand mean for all subjects on Section I = 20.52 " (highest possible score 26) .

PAGE 53

44 Table 8 Analysis of Group Performance on Section II Medical Gas Therapy Group I Group II Group III Coursework Coursework Experienc and Only Only Experience Score Rank Score Rank Q /-> /.-\ -V— /-J 18 2 17 4 16 6 18 2 16 6 12 11.5 18 2 13 9.5 11 14 16 6 13 9.5 10 16.5 14 8 12 11.5 7 18.5 11 14 7 18.5 11 14 10 16.5 M 16.8 T. 20 J M 12.87 T. J 85 M 10.5 T. 85 J T? 400 T? J 7,225 Tj 7,225 n=5 n= = 8 n=6 h' = = 9.0723, significant at E< .05, 2 df. Grand mean for all subjects on Section II = 13 15 (highest possible score 26) .

PAGE 54

45 Table 9 Analysis of Group Performance on Section III Humidity Therapy Group I Group II Coursework Coursework and Only Experience " S P OTP ocore Kanic Score Rank 21 1 15 4 14 7 17 2 15 4 14 7 15 4 14 7 13 10 13 10 13 10 11 13 11 13 11 13 .9 17 10 15.5 8 18.5 10 15.5 8 18.5 M 15.4 T. 30 J M 12 T^ 87.5 M 11.5 T. 72.5 J T? 900 J T? 7,656. 25 T? J 5,256.25 n=5 n=8 n=6 H = 3.57, nonsignificant at £ < . 05, 2 df. Grand mean for all subjects on Section III 12 73 (highest possible score 26). Group III Experience Only

PAGE 55

46 Table 10 Analysis of Group Performance on Section IV Intermittent Positive Pressure Breathing Group I Coursework and Experience Group II Coursev7ork Only Group III Experience Only Score Rank Score Rank Score Rank 20 1.5 19 3, ,5 20 1.5 18 6 19 3, .5 17 9.5 , 16 14 18 6 17 9.5 16 14 18 6 17 9.5 15 18 17 9, .5 16 14 16 14 15 18 16 14 15 18 M 17 T. 53.5 J M 17.25 T. 74, J ,5 M 17 T. 62 J 2862.5 J ' T? 5^50.25 T? 3844 J ' n=5 n=8 n=6 H = .2193, nonsignificant at £ < .05, 2 df. Grand mean for all subjects on Section IV = 17.1 (highest possible score 25) .

PAGE 56

47 Table 11 Analysis of Group Performance on Section V Respiratory Therapy Pharmacology Group I Group II Group III Coursework Coursework Experience and Only Only Experience Score Rank Score Rank Score Rank 17 2 13 7 22 1 18 3 13 7 13 7 14 4 13 7 11 14 12 11 13 7 9 16 11 14 12 11 8 17.5 12 11 6 19 11 8 8 17.5 I 14.8 T. 34 J M 11.87 Tj 81.5 M 11.5 1. 74.5 T? i;.56 T? 6,642.25 T? J 5^50.2! n=5 n=8 n=6 H = 2.7323, nonsignificant at £< .05, 2 df. Grand mean for all subjects on Section V = 12.52 (highest possible score 26) .

PAGE 57

48 Table 12 Analysis of Group Performance on Section VI Cardiopulmonary Resuscitation Group I Coursework and Group II Coursework Only Group III Experience Only Score Rank Score Rank Score Rank 23 1.5 22 3.5 21 5 23 1.5 19 8.5 19 8.5 22 3.5 18 11.5 18 11.5 20 6.5 17 15 18 11.5 20 6.5 17 15 18 11.5 17 15 16 17.5 16 17.5 13 19 M 21.6 T. 19.5 H 17.37 T. lO'^. J M 18.33 Tj 65.5 380.25 T? 11,025 J 4,290.25 n=5 n=8 n=6 K 8.504, significant at d < .05, 2 df Grand mean for all subjects on Section VI = 18 78 (highest possible score 30) .

PAGE 58

49 Table 13 Analysis of Group Performance on Section VII Cardiopulmonary Anatomy and Physiology Group I Group II Group III Coursework Coursework ' Experience and Only Only Experience Score Rank Score Rank Score Rank 37 1.5 37 1.5 33 6 36 3 33 6 26 13 34 4 32 8.5 25 15 33 6 29 Id 23 16.5 32 8.5 28 11 21 18 26 13 18 19 26 13 23 16.5 M 34.4 T. 23 M 29.25 T. 79.5 M 22.66 T. 87.5 J J J T? 529 J T? J 6^20.25 T? J 7,656.25 n=5 n= = 8 n=6 H = 8.5854, significant at £< .05, 2 df . Grand mean for all subjects on Section VII = 29.05 (highest possible score 52) .

PAGE 59

50 Section I Introduction to Resoiratory Therapy (Table 7) Section II Medical Gas Therapy (Table 8) Section VI Cardiopulmonary Resuscitation (Table 12) Section VIICardiopulmonary Anatomy and Physiology (Table 13) Th erefore, the null hypotheses (1, 2, 3, 7, and 8) were rejected and the research hypotheses (1, 2, 3, 7, and 8) accepted. Null hypotheses (4, 5, and 6) could not be rejected, since no significant differences in mean scores were found among the groups. Examination of group means on the total examination and the seven course examinations revealed some interesting and unexpected findings. Group I scored higher than Groups II and III on the total examination and on the following course examinations : Section II Medical Gas Therapy Section III Humidity Therapy Section V Respiratory Therapy Pharmacology Section VI Cardiopulmonary Resuscitation Section VII Cardiopulmonary Anatomy and Physiology The test content of the five courses listed above demanded not only recall of important facts but required the examinee to apply facts to problem-solve and make difficult, clinical judgments. The clinical experience of subjects in Group I may have enhanced the knowledge gained from their coursework at Santa Fe , thus, accounting for their higher performance.

PAGE 60

51 Also, the FTGAT scores of subjects in Group I suggested that overall, they were more test-wise than examinees in Groups II and III. Group II scored higher than Groups I and III on Section I (Introduction to Respiratory Therapy) and Section IV (Intermittent Positive Pressure Breathing) . Groups I and III may have had negative work experiences in these two areas, possibly acquiring inaccurate information, that accounted for their lower performance. The test-content of Section I demanded recall of information that respiratory therapists needed to know about the AART to pass the national registry examination. Intermittent Positive Pressure Breathing has been an area of controversy v/ithin the field and practices vary widely from hospital to hospital. The quality of experience no doubt played an important factor in either supplementing theory or adding confusion, depending on whether the experiences were based on sound principles of practice. Group III scored higher than Group II on Section VI (Cardiopulmonary Resuscitation) and equally as well as Group I on Section IV (Intermittent Positive Pressure Breathing) . Most subjects in Group III had participated in cardiopulmonary resuscitation in the hospital setting and had attended periodic inservice training programs to improve their skills in life-saving techniques. The coordinator of the Respiratory Therapy Program and the investigator established that the grand mean of the 19

PAGE 61

52 subjects on each section examination would be the criterion for acceptable performance; this decision was based on the belief that candidates applying for advanced standing should be evaluated according to the mean performance of generic students on the seven course examinations. Thus, if subjects in Group III scored the grand mean or higher on a section, then they qualified to take the respective clinical examination. Using the above criterion, the following courses were passed by the number of examinees listed below, according to group membership. Percentages of each group that passed are shown in parentheses (Table 14) . Table 14 Courses Passed by Group Members Group I Group II Group III Coursework Coursework Experience Course and Only Only Experience Introduction to Respiratory Therapy 4 (80%) 8 (100%) 1 (16. , 6%) Medical Gas Therapy 5 (100%) 7 (87.5%) 1 (16. , 6%) Intermittent Positive Pressure Breathing 2 (40%) 5 (62.5%) 4 (66. .6%) Humidity Therapy 4 (80%) 4 (50%) 3 (50%) Respiratory Therapy Pharmacology 3 (60%) 6 (75%) 2 (33. .3%) Cardiopulmonary Resuscitation 5 (100%) 3 (37.5%) 5 (83. 3%) Cardiopulmonary Anatomy and Physiology 5 (100%) 5 (62.5%) 1 (16. 6%)

PAGE 62

53 One examinee in Group III attained the third highest score on the total examination and also passed the seven course examinations; this person was reported to be an outstanding worker, with six years of experience in the field, who was eager to learn new techniques and theory and often attended continuing education programs in respiratory therapy. Students in Groups I and II purported to have spent little or no time preparing for the examination because they were too busy studying for final examinations. In general, respiratory therapy personnel reported they had tried to review as many of the objectives as possible. Thus, it was difficult to account for variance in scores due to individual variances in preparation for the examination. Conclusions Item analysis and review of the groups' performances on the cognitive model served to identify strengths and weaknesses of the examination. Although the reliability of the examination was acceptably high (.8 8), the previously mentioned revisions should serve to increase the reliability and improve questions that were ambiguous or specious. The cognitive model appeared to be an appropriate, diagnostic method for identifying experienced respiratory

PAGE 63

54 therapy personnel, who have adequate theoretical knowledge in the field, to qualify to take the clinical examination. Until the cognitive model has been tested with larger samples, no further revisions were deemed necessary. Future item analyses will assist examiners in constructing a large file of the best test-items to include in future testing . models. The analysis of variance indicated whether there were significant differences in knowledge among groups. With larger samples, parametric analysis of variance could be employed and if significant differences were found, then an appropriate t-test, such as Schefe's, could be applied to discern where significant differences among groups occurred (Hays, 1973).

PAGE 64

CHAPTER IV EVALUATING THE CLINICAL MODEL Three male subjects who had passed one or more sections of the cognitive examination were available to take the clinical examination. Subjects volunteered to take all five portions of the clinical examination so that the feasibility of the entire model could be evaluated. The courses tested were RS 101 Introduction to Respiratory Therapy RS 121 Medical Gas Therapy RS 122 Humidity Therapy RS 123} _ {Intermittent Positive Pressure Breathing RS 141} {and Respiratory Therapy Pharmacology RS 151 Cardiopulmonary Resuscitation Prior to testing the clinical model, the test situations and equipment and personnel schedules were reviewed to guarantee that examinees would have the proper support to perform the expected affective and psychomotor skills. The respiratory therapy teaching laboratory was arranged to examine candidates for psychomotor skills and a classroom was designed with the necessary equipment to simulate a hospital room so that affective skills could be examined. The classroom was also equipped with a camera and audiovisual accessories for videotaping the role-playing situations. ^' 55

PAGE 65

56 All participating faculty examiners, actors, and the camera technician were briefed regarding the examination checklist, sequence of events, and behaviors expected of the actors, examinees, and examiners. A trial run was conducted to affirm that all equipment was in place and functioning properly. One faculty member was stationed in the laboratory to test for psychomotor skills and the other faculty member, actors, and camera technician were in the simulatedhospital room to test for affective skills. Only one examinee could be tested at a time, in each room. Total time to complete the entire clinical examination was approximately 90 minutes: 20 minutes for the affective skills and 70 minutes for the psychomotor skills. The critical time limits imposed for all of the testing situations in the clinical model totals 79 minutes but additional time is required to "set the stage" after an examinee has completed a section. The critical time limits were established by the four respiratory therapy faculty members and the investigator; all examinees were able to perform within the established time limits. No problems were encountered during the testing of psychomotor skills. The three subjects who participated in the clinical examination had little or no previous experience with roleplaying. The examiners and actors "set the stage" for each simulation and allowed the examinees time to mentally prepare themselves for the situation. The three role-playing

PAGE 66

57 situations were videotaped for analysis by three respiratory therapy faculty to obtain inter-rater reliability. A checklist of expected behaviors was used for the role-playing ' situations that aimed to measure prespecified qualities of• the examinee: listening ability, verbal expression, empathy, appropriateness of response to emotional cues, and judgment. All subjects performed satisfactorily during the role-playing situations . . . ^ The highest possible score a subject could attain on the clinical model was 312. The lowest possible score a subject could receive and still pass all 5 sections, including critical skills, was 234. The subjects' scores were 216, 261, and 281. Each section of the clinical model had to be evaluated separately to discern whether the examinee passed the required critical skills; if any portions of the critical skills were not met, then the examinee failed that particular section. Only one of the role-playing situations was desig^nated a critical skill, the rationale being that the specified situation was one often encountered in hospitals and competent respiratory therapists would be able to solve the problem effectively. In addition to performing psychomotor and affective skills, subjects were required to present American Heart.. Association certificate cards (Level II and V) to document, successful performance of basic and advanced life-suDport skills in cardiopulmonary resuscitation. The American Heart

PAGE 67

58 Association has offered courses locally to certify persons to perform cardiopulmonary resuscitation at five different levels: Level I (a basic course for lay persons) to Level V (the most advanced course for health professionals) . Future testing of affective skills, utilizing roleplaying, will be required to evaluate the validity and reliability of the clinical model for measuring desirable qualities that are required of competent respiratory therapists. Critics may argue that the checklists used in the clinical model were not completely behavioral nor were they totally objective. The examiner must make a judgment as to whether the behavior occurred and if it did, must decide how well the examinee performed. Astute observational skills were required of examinees and because of the element of subjectivity, the inter-rater reliability method was used to score the role-playing situations. The clinical model represented an initial effort to ^ quantify and measure critical psychomotor and affective skills of respiratory therapy personnel applying for advanced standing. Merhens and Lehmann reported a dismal outlook: "Whether or not tests of noncognitive variables will ever be successful as selection instruments is debatable because the problem of faking will always exist to some degree" (1973, p. 677). Although measurement in the affective domain was the most difficult task, educators cannot continue to ignore this important area of instruction and evaluation. With

PAGE 68

59 future trials of the clinical model, no doubt the measurement techniques can be refined. Recommendations for Future Research and Utilization Findings of the study supported the continued development and use of validation examinations for respiratory therapy personnel applying for advanced placement to the respiratory therapy program at Santa Fe Community College. The validation examinations provided formal mechanisms for granting academic credit and advanced placement. Based on initial testing and evaluation of the cognitive and clinical models, the following recommendations for further research both at Santa Fe and in related programs were proposed: 1. Perform several testing sessions with similar groups of students, as used in the present study, so that appropriate measures can be taken to improve the validity and reliability of the cognitive and clinical models. Analyses of examinations by computer and storage on magnetic tape will provide a useful data bank for future testing with subsequent groups and will also help to accumulate a test file of the hest items to include in future examinations. 2. Periodically update the examinations whenever course objectives are revised to maintain content validity of the examinations. Most achievement tests have been criticized because they do not reflect the educational objectives of the

PAGE 69

60 program (Tyler and Wolf, 1974) . Because the cognitive and clinical models were based on objectives of the first-year Respiratory Therapy Program at Santa Fe Community College, they do possess content validity and are appropriate instruments for assessing knov/ledge of candidates applying for advanced standing. 3. Use objectives from the seven courses under study to assess a candidate's readiness to take the validation examination, identify specific strengths and weaknesses of applicants and prescribe learning activities to enhance chances of successful performance on the examinations. 4. Grant advanced placement to candidates who pass one or more sections of the validation examinations and assist them to either continue an individualized, formal program of study or join generic students at the appropriate course level 5. Employ the cognitive and clinical models annually or semiannually for summativetype evaluations of generic students in the respiratory therapy program to assess progress and effectiveness of the instructional program. Compare students' achievement on the examinations later with their performance on the national registry examination to provide follow up and accountability (Ryan, 1975). 6. For the more advanced courses offered during the second year of the respiratory therapy program, develop a branching examination that tests primarily for clinical problemsolving skills and serves as an alternative to the multiplechoice format (Mehrens and Lehmann , 1973).

PAGE 70

61 7. In future cognitive models, incorporate an additional type testing format: the use of well-constructed essay tests to provide a means of testing an examinee's ability to compose a logical answer and present it in an acceptable, written style. Evaluators must keep in mind that, contrary to popular belief, no evidence exists to support the claim that only the essay test can be used to measure higher mental processes of organization, analysis, and evaluation (Mehrens and Lehmann, 1973, p. 213). 8. Since test-wise students are likely to perform higher on the cognitive examination, direct candidates who have a previous record of poor performance on national achievement examinations such as the FTGAT or the SAT, to improve their test-taking skills via one or more methods: a. independent study of textbooks designed to help persons become more test wise (Millman and Paulk, 1969 or Juola, 1968). b. enrollment in specially-designed night courses that assist students in improving test-taking skills and overcoming test anxiety. 9. Consider that many respiratory therapy personnel may have been denied admission to academic programs because they could not meet entry-requirements or pass standard achievement examinations used in the selection of students. The proposed cognitive and clinical testing models were designed to accommodate varied learning and performance styles of examinees. Previous researchers have proposed that the cognitive styles of learners be identified to plan individualized instruction

PAGE 71

62 (Nunney, 1975). For future research, include the identification of examination-performance styles of individuals, thus offering alternative forms of testing to candidates who are clinically proficient but unable to perform well on cognitive examinations . 10. With permission of the examinees who participated in the role-playing situations, use the videotapes for either instructional or evaluation purposes. A student might be asked to view the role-playing situation and identify the correct or incorrect practices performed by the therapist. This technique offers an alternative assessment procedure, if role playing is later judged to be an unreliable method of testing affective skills. 11. Employ the videotapes for teaching interpersonal relationships to generic students in the respiratory therapy program (Tansey, 1971). Construct teaching files of roleplaying situations to provide students with models of behavior that are expected of respiratory therapists.

PAGE 72

63 Summary Important decisions are frequently made on the basis of one or more types of achievement examinations, such as granting advanced placement to successful candidates or admitting students to academic programs. For this reason, educators must know whether the examinations that v;ere employed in decision making were given the correct emphasis and if the evaluation instruments provided accurate assessments of examinees' knowledge and performance levels. Examinations that fail to possess adequate validity and reliability must be rejected, especially where decisions are made regarding a person's educational future. As a result of inadequate, evaluation procedures, many qualified persons may be "sorted out" and labeled "undesirable." Evaluation must not be viewed, in this context, as a punitive procedure but as a diagnostic, prescriptive, and therapeutic process that was intended to assist individuals in achieving attainable career goals. The cognitive and clinical models that were developed in the present study represented initial efforts to provide formal mechanisms for granting academic credit and advanced placement to qualified respiratory therapy personnel; the models applied only to the respiratory therapy courses offered the first year at Santa Fe Community College.

PAGE 73

64 Using the Kruskal-Wallis nonparametric analysis of variance procedure, significant differences in mean performance on the total respiratory therapy validation examination and four section examinations were found (p < .05). Therefore, the following null hypotheses for the cognitive model were rejected and the research hypotheses accepted: 1. H^: No difference in mean scores on the total respiratory therapy validation examination (RTVE) will be found between the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on the total RTVE . 2. H^: No difference in mean scores on Section I of the RTVE will be found between the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on Section I of the RTVE. 3. H^: No difference in mean scores on Section II of the RTVE will be found between the three groups. H^: At least one of the three groups differs from the others with respect to mean scores on Section II of the RTVE. 7. H^: No difference in mean scores on Section VI of the RTVE will be found betv/een the three groups. At least one of the three groups differs from the others with respect to mean scores on Section VI of the RTVE. 8. H^: No difference in mean scores on Section VII of the RTVE will be found between the three groups. H a H : a At least one of the three groups differs from the others with respect to mean scores on Section VII of the RTVE. With larger samples, parametric analysis of variance could be employed and if significant differences were found,

PAGE 74

65 an appropriate t-test, such as Schefe's, could be applied to discern v/here significant differences among groups occurred (Hays, 1973). Evaluation of both models with candidates provided evidence that there are respiratory therapy personnel who have acquired adequate knowledge and experience to paas the equivalency examinations and earn academic credit. With the previously mentioned revisions and future testing programs, the validity and reliability of the multidimensional testing models would be improved. Educational readiness of an academic program and the program's ability to supply the necessary time, faculty, and expenditures must be assessed before equivalency evaluation is undertaken. Findings of the study warranted the development of equivalency testing models for the respiratory therapy courses offered the second year at Santa Fe Community College. Increased demands for improvement of health care delivery to consumers suggest that educators of other allied health programs consider the development and use of validation examinations to encourage health personnel to maintain and upgrade standards of care, while protecting their future in the field.

PAGE 75

BIBLIOGRAPHY Adkins , D.C. Statistics: An introduction for students in the behavioral sciences. Columbus, Ohio: Charles E. Merrill Inc., 1965. Banathy, B.H. Instructional systems. Belmont, California: Fearon Publishers, 1973. Beauchamp, G. Curriculum theory. Wilmette, Illinois: Kage Press, 1975. Bresinski, M.E. Management education opportunities not well used. Respiratory care, 1975, 20, 718. Comroe, J.H. Physiology of respiration (2nd ed.). Chicago: Yearbook Medical Publishers, 1974. Cronin, M. Internships for respiratory therapy. Respiratory Therapy, 1976, 6, 39-41, 59. Davis, R.H., Alexander, L.T. and Yolon, S.L. Learning system design: An approach to the improvement of instruction. New York: McGraw-Hill, 1974. Demers , R.R. Is the respiratory therapist an endangered species? Respiratory Care, 1976, 21, 620. DeShaw, B.L. Developing competencies for individualizing instruction. Columbus, Ohio: Charles E. Merrill Inc 1973. ' Egan, R. Fundamentals of respiratory therapy. St. LouisC.V. Mosby, 1975. Essentials of an approved educational program for the respiratory therapy technician and the respiratory therapist Respiratory Care, 1972, 17, 679-684. Fehling, E.H. Oral exams should be in clinical settings. Respiratory Care, 1976, 21, 489. Ford, C.W. and Morgan, M.K. (Eds.). Teaching in the health professions . St. Louis: C.V. Mosby, 1976. 66

PAGE 76

67 Fox, D.J. The research process in education . New York: Holt, Rinehart and Winston, 1969. Gage, N.L. Handbook of research on teaching. Chicago: Rand McNally, 1963. Gagne, R.M. and Briggs , L.J. Principles of instructional design. New York: Holt, Rinehart and Winston, 1974. Goolsby, T.M. Comparability and validity of three forms of SCAT. Educational Measurement, 1967, 27, lOAl-1045. Hatch, T.D. Allied health manpower— Direction for the 1970s and 1980s. Respiratory Care, 1911, 16, 7-10. Hays, W.L. Statistics for the social sciences , Nev/ York: Holt, Rinehart and Winston, 1973. Helmholz, H.F. Report from the joint review committee for inhalation therapy education. Respiratory Care, 1972 17, 692-694. Irby, D.M. and Dohner, C.W. Student clinical performance. In Ford, C.W. andllorgan, M.K. (Eds.). Teachina in the Health Professions . St. Louis: C.V. Mosby, 1976. Irby, D.M. and Morgan, M.K. (Eds.). Clinical evaluation: Alternatives for health related educators . Gainesville, Fla.: Center for Allied Health Instructional Personnel! 1974. Juola, A.E. Examinations (Skills and techniques) . Lincoln Nebraska: Cliff's Notes, 1968. Kerlinger, F.N. Foundations of behavioral research. New York: Holt, Rinehart and Winston, 1973. Kerr, E.E. Utilization and preparation of personnel to deliver health care. Respiratory Care, 1971, 16, 41-48. Kittredge, P. A proposal for recredentialing respiratory therapists and technicians every five years. Respiratory Care, 1975, 20, 433-440. Krathwohl, D., Bloom, B. and Bartram, M. Taxonomy of eduaatzonal objectives , Handbook II: Affective domain. New York: David McKay, 1968. Mager, R.F. Developing attitude toward learning. Palo Alto California: Fearon Publishers, 1968.

PAGE 77

68 Mager R.F. and Pipe, P. Analyzing performanae problems. Belmont, California: Fearon Publishers, 1970. Mathewson, H.S. The respiratory therapist's role in critical care. Respiratory Care, 1976, 21, 29-32. McAleer, W.M. Proposal for tv;o routes to certification Respiratory Care, 1975, 20, 782. Mehrens, W.A. and Lehmann, J.J. Measurement and evaluation tn educatvon and psychology . New York: Holt, Rinehart and Winston, 1973. Mendenhall, W. , Ott, L., and Larson, R.F. Statistics: A tool for the social sciences. North Scituate, Mass • Duxbury Press, 1974. Mendoza, J. Everyone should be credentialed . Respiratory Care, 1915,20, 1102. ^ Millman, J. and Paulk, W. How to take tests. New YorkMcGraw-Hill, 1969. Noll, V.H. and Scannell, D.P. Introduction to educational measurement . Boston: Houghton Mifflin, 1972. Nunney, D.N. Educational cognitive style: A basis for personalizing instruction. Educational Scientist 1975 1, 13-26. ' Occupational outlook handbook, 1976-1977 edition. Washington, D.C.: US Government Printing Office, 1976. Perry, D.F. Constructing useful objectives in respiratory therapy. Respiratory Care, 1976, 21, 327-332. Petty, T.L. Pulmonary diagnostic techniques . PhiladelphiaLea and Febiger, 1975. Popham, J.W. Educational statistics: Use and interpretation New York: Harper and Row, 1967. Popham J.W. and Baker, E.L. Systematic instruction: Englewood Cliffs, New Jersey: Prentice Hall, 1970. Powers, W.E. Upward mobility for anyone who can climb Respiratory Care, 1975, 20, 1054-1055. Powers, W.E. Improving clinical problem-solving performance Respiratory Care, 1976a, 21, 229-231.

PAGE 78

69 Powers, W.W. Upward mobility through schools is unnecessary. Respiratory Care, 1976b, 21, 369. Publication manual of the American Psychological Association (2nd ed. ) . Washington, D.C.: American Psychological Association, 1975. Radocy, R.C. Quantification of affective behavior. Chicago, Illinois: Paper presented at the national Council on Measurement in Education, April 18, 1974. (ERIC NO ED 090265) Raths, L.E. Teaching for thinking. Columbus, Ohio: Charles E. Merrill, 1967. Redman, R.R. Are oral exams valid? Respiratory Care f 191() . 21, 252-253. Respiratory therapy task analysis. Unpublished manuscript, 1975. (Available from Santa Fe Community College, Respiratory Therapy Program, Gainesville, Fla.). Rosenbaun, P.S. Peer-mediated instruction. New York: Teachers College Press, 1973. Ryan, C. Career education: A handbook of funding resources (3rd ed. ) . Boston: Houghton Mifflin, 1975. Sanderson, R. Survey of respiratory therapy manpower in Florida. Unpublished manuscript, 1976. (Available from Santa Fe Commnity College Respiratory Therapy Proeram Gainesville. Fla.). i'J b . Saposnick, A.B. and Weslowski, W.E. College-hospital financial arrangements for clinical instruction and supervision: A survey. Respiratory Care, 1976, 21, 225-228. Saylor, J.G. and Alexander, W.M. Planning curriculum for schools. New York: Holt, Rinehart and Winston, 1974. Scanlan, C.L. Continuing education in the health professions: Mandatory or voluntary? Respiratory Care, 1975, 21, 823827 . Scannell, D.P. and Tracy, D.B. Testing and measurement in the classroom. Boston: Houghton Mifflin, 1975. Simon, S.B., Howe, L.W. and Kirchenbaum, H. Values clarificatvon: A handbook of practical strategies for teachers and students. New York: Hart, 1972.

PAGE 79

70 Stanley, J.C. and Hopkins, K.D. Educational and psychological measurement and evaluation. New Jersey: Prentice Hall, 1972. Stufflebeam, D.I., Foley, W.J., Gephart, W.J., Cuba, E.G., Hammond, R.L., Merriman, H.O. and Provus , M.M. Educational evaluation and decision making. Itasca, Illinois: F.E. Peacock Publishers, 1971. Taba, H. Curriculum development : Theory and practice. New York: Harcourt, Brace and World, 1962. Tansey, P.J. Educational aspects of simulation. LondonMcGraw-Hill, 1971. Taylor, J.L. and Walford, R. Simulation in the classroom. Baltimore: Penguin Books, 1972. Tyler, RW. and Wolf, R.M. (Eds.). Crucial issues in testing. Berkeley, California: McCutchan Publishing Corp., 1974. Whitacre, J.F. Striving for professionalism. Respiratoru Care, 1971, 16, 277-280. ^ Whitacre, J.F. Beginnings and development of the AAIT Respiratory Care, 1912, 17, 491-493. Wilson, M.A. Equivalency testing in development of health practitioners. Journal of Allied Health, 1974, 3, 103-109. Wilson, M.A. Equivalency. In Ford, D.W. and Morgan M K (Eds.). Teachvng in the Health Professions. St LouisC.V. Mosby, 1976. Youtsey, J. A proposed mechanism for upward mobility through 1050-1052^'^°'^^"^ programs. Respiratory Care, 1975, 20,

PAGE 80

APPENDIX A Santa Fe Community College Credit By Exam Policy Requirements for credit in a number of college courses may be satisfied by successful completion of either a CLEP exam or a discipline/program area made exam, .when a subject matter or general CLEP exam is not available. Evidence of proficiency in any given subject area, when presented to the' Of f ice of Academic Affairs and discipline/program area, shall qualify a student to request an examination. The proposed policies for institutional credit by examination are : A student may not challenge a course if he/she attended that particular course at Santa Fe Community College and received a grade of A, B, C, WI or I if he/she has earned credit for an advanced course in that area. Decisions as to whether or not a student has earned credit for an advanced course in the discipline/program area will be determined by the instructor from the area giving the examination. Examinations for credit by exam may be attempted by the second time after the lapse of one full academic term beyond the term in which the first attempt was made. A student may not attempt credit by exam more than twice in the same course. Credit by exam will not be available during the period between official college terms or during official college holidays. Credit by examination will not be counted in the student's load, but will be computed in the current grade point average. An administrative fee of $15 will be charged prior to each credit by exam attempt. Students are required to be currently enrolled at Santa Fe in order to challenge a course. At least 15 hours of the degree program, AA or AS , must be completed in the classroom. Upon conclusion of the credit by examination by other than CLEP, a copy of the graded examination shall accompany the credit by examination approval form to Academic Affairs. With the approval of Academic Affairs on the completion of the examination, the request form will be validated and the exam copy filed. 71

PAGE 81

APPENDIX B The Models— Obtaining Information Because the cognitive and clinical evaluation models will be used in subsequent equivalency examinations at Santa Fe Community College, the models cannot be included in the study. Investigators who would like to replicate the study may obtain more information about the models and complete copies of all course objectives, from which both testing models were derived, by writing to this address: Director, Respiratory Therapy Program Santa Fe Community College South Campus Gainesville, Florida 32601 72

PAGE 82

X H >< O H M P-i o H o M H O :3 Q o H c/3 (U •u c o u I w o X) 4-1 (U MM u-^ •rH -1-4 0) CO < > u r-( CO hJ U-l O 'O 0) >^ •H >^ C7 0) o Pi e M :s O •H > CI! OJ CO ;3 C r-l O CO > -U I •H e c •rH O a 4J C/3 CO •H C Q DO H K> K>< kS kN x; XXX X K> kS kN o •H 4-J >^ CO O O 4-1 •1-1 d o •iH 4-1 (t N 1-1 Pi CO^ M U M-l O O in CM o CN X x: X X X X X X X X X X CO T) ^1 I— 1 i-H to O CO CO a CO a M C cu cu o j:: 4J O 4J M CO CO 4-1 U) •H 1 CO M C 14-1 CO -r^ rH 01 O O U fX CO CO 0) CU•r^ H CO i-H o a r-l U -u (U a. M CO •rH •H 0) CO t— 1 CO 0) 4-1 T) XI o 4-1 ,-1 o X X J-l CO CJ CJ I-H iJ CO CO rH e CO CO d QJ QJ CO X H

PAGE 83

•rH -H is m in o CM CsJ LO LO 0) > X X XX XX X X X u o X X XX XX X I r-H O > w X X X •H B C •H O CJ 4-J Q X X X X X o •H a o to M-l >^ O u U W woe e CO txo 0) >^ U Oh O 0) M >, !-l Q) O 14-1 w 4-1 CO B 4-J CO C O CO CO cx CO 5-1 Q) H QJ bO >^ X o •H 1 CO CO > :3 >, to •H 4-1 i-l CJ d t— 1 to CO •iH o o , >^ to cx X u 4-) to O QJ O o o a o

PAGE 84

U OJ •r-l -r-l o CM o in in u > X X X c X X X X X X >u o E 0) X X X X X X X I D C rH O CD -H > 4-J w X X X X X X X I •H E C •H O ^ -H O 4-) cn CO •H c Q o O H X CO >^ O o en u B 0) o H CO CO O 4:; (U X c CO I CO CJ ^^ o 'a 4J -H o CO CO O 5-1 CO •^^ 4-1 c c o CO U CL, < M U -U CO CU o CO o u cu X X X X X u (U > T3 •H C 0 rH CO •iH CU CO 4-) CO CO 0 Q CO -rH CO !-i CO >H C c c •H c CO C 0 CU 0 co^ CO u c U VWJ CU u CU 0 0 a CU CU CU Ci (U 1-H 0) 4-t QJ CO (U <: 0 <: <; H C_> H CO H M H

PAGE 85

•H -H <: r— 1 CD U > M u X 0) c <: w rH tC PQ hJ c W o CO QJ PL, :3 cr u w 0 > M H S M o o > PM H 1 Is w H >-i 0 H M > 4.) S w w H <^ M CO 1 •H eg E C I— 1 •H 0 1 0 4-1 C Q c 0) 0 U •H . a 0) 0 CO H ;3 0 0 o Csl X X I •r< I pq XI 13 OJ (X, C C o p-i M cfl -H M c ^ >s W -H O O O 4-) -H W 4J O Csl O O O O X O H X X X CO U ^-1 4-1 W M CD •H 3 >-< 4-1 CO -H PQ (U •r-t CO 4J P-i 4-J CO (U C PL, C 0 (-4 0) M M Pt, PLj > X o •H 4J CD iJ C 01 G 13 V< iJ CO C

PAGE 86

!-i > 0) >< U o CC o OJ J o u C O i red Pm ui CJ RAP Re emo w S-i o H •H > >-i x: 1 O H PQ 13 c •u C 0) •M c o o I (U (0 o •u cu •r-l -H 0) w 0) > -u I 6 H U W CO CO o •H o H o CM X X! X X in CN rH CO CO 1 a >-l u C CO 0 •H O p MO CO O 0 r-l .-I •H •H O t/3 Tl O CO C 0 0 0 2 e o <; -H a >-l 4-1 to bO U C CO CO ^-1 13 CO 0 4:; 0) u p^ zn > 0 oi in CN O u CO ^1 •H CI, CO -J CO C O CO g 00 o M a Q CO :=) >. .—I c O CO E W) B 3 O ^-1 U Q

PAGE 87

•u X X X X X X X X X X X X X X X X X X X X X X X X X X X X 01 •u a 3 U 4-J CO o CU CO to XI 4-) c CU s >. CU CO tiO •-I CO < s

PAGE 88

Ln m o o o r-i I— I CM CM CNl X X X X X X X .X XXX X X X X X X X o o -u T) m H >>^-l(I;>^ ocxo wcco

PAGE 89

APPENDIX D DESCRIPTIVE' DATA OF RTVE SCORES INSTRUCTOR MOODY NUMBER OF STUDENTS TAKING TEST TOTAL NUMBER OF ITEMS ON EXAIl COURSE NAME SFCC RESP . RANGE OF SCORES THERAPY DEPARTMENT OF HIGH = LOW = HIGHEST POSSIBLE SCORE MEAN (AVERAGE) RAW SCORE TEST TITLE MEDIAN (MIDDLE) RAW SCORE DATE OF EXAM DEC 1976 STANDARD DEVIATION (RAW SCORE) KUDER-RICHARDSON 20 CORRELATION 19.00 210.00 155.00 93.00 210.00 124.00 124.00 17.07 0.88 ALL SCORES AND STATISTICS COMPUTED ON THIS PAGE ARE BASED ON PvAW SCORE. 80

PAGE 90

FREQUENCY DISTRIBUTION OF RTVE SCORES RAW PERCENT FREz PERCENTILE NUMERICAL SCORE SCORE QUENCY SCORE RANK RANK 93 44 .28 1 -1 .81 0, .00 19 98 46 . 66 1 -1 . 52 5 26 18 107 50, ,95 1 J-0 .99 10 .52 1 7 109 51, .90 1 -0 .87 15 .78 ' 16 113 53, .80 1 -0 .64 21 .05 15 116 55. .23 2 -0 .46 31. ,57 13 118 56, ,18 2 -0 .35 42. ,10 .11 124 59. ,04 2 0 .00 52, ,63 9 125 59. ,52 1 0 .05 57. ,89 8 128 60. ,95 1 0 .23 63. • 15 7 136 64. ,76 1 0 . 70 68, ,42 6 139 66. 18 1 0 .87 73. ,68 5 : 143 68. 09 1 1 .11 78, ,94 4 145 69. 04 1 1 .23 84. 21 3 149 70. 95 1 1 .46 89. 47 2 155 73. 30 1 1 .81 94. 73 1 81

PAGE 91

BIOGRAPHICAL SKETCH Linda Elizabeth Moody was born in Tampa, Florida on June 30, 1941. She V7as graduated from Brandon High School in 1959 and received a diploma to practice professional nursing from Gordon Keller School of Nursing in 1962. Pursuing her nursing career at the University of Florida, she earned a Bachelor of Science degree in Nursing in 1965. Upon graduation, she served for three years in the U.S. Army Nurse Corps at the following installations: Walter Reed Army Hospital, Washington, D.C., 85th Evacuation Hospital, Quinhon, Vietnam, and, U.S. Army Recruiting Center, Jacksonville, Florida. After earning the Master of Nursing degree in 1969 from the University of Florida, she remained and taught there for four years in the College of Nursing. Because of her special interest in pulmonary diseases, the Florida Lung Association granted financial support for postgraduate study at the University of Arizona, where she received a certificate as a Pulmonary Clinical Nurse Specialist in December, 1972. Since 1973, she has been employed as a Pulmonary Clinical Nurse Specialist at the Veterans Administration Hospital, Gainesville, Florida. Several of her articles regarding pulmonary care have been published in national nursing 82

PAGE 92

83 and medical periodicals. Memberships in professional organizations include Sigma Theta Tau, Pi Lambda Theta, Kappa Delta Pi, American Nurses' Association, and Outstanding Young Women of America.

PAGE 93

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Margaret K. Morgan, Chairman Associate Professor of Curriculum and Instruction I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. 7 Amanda S . Baker Associate Professor of Nursing I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy James W. Hensel Professor of Curriculum and Instruction I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Associate Professor of Curriculum and Instruction

PAGE 94

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Carol E. Taylor*^ Assistant Professor of Nursing This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate Council, and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. March 1977 Dean, College of Education Dean, Graduate School