Research for evidence based practice

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DISCUSSION 

QUANTITATIVE ANALYSIS AND INTERPRETATION: T-TEST AND ANOVA

  

ASSIGNMENT: 

T-TESTS AND ANOVA

QUANTITATIVE ANALYSIS AND INTERPRETATION: T-TEST AND ANOVA

  

DISCUSSION

Statistics provide a variety of information that can shape healthcare. Statistics can indicate disparity in care, effectiveness of treatments plans, and predict future outcomes. As a future DNP-prepared nurse, understanding how to analyze and interpret statistics will provide you the opportunity to utilize research in directing patient care and implementing procedures to ultimately improve patient success.

When comparing patients, treatment methods, or healthcare practices, it will be important to consider differences amongst groups. Statistics give us the opportunity to explore and determine these differences to properly analyze the data, make recommendations, or determine treatment options. As a DNP-prepared nurse, using statistics to determine differences may assist you in making the best decisions for your patients and practice. 
This week, you will examine the use of inferential statistics in research. You will also consider the strengths and weaknesses of using both 
t-tests and ANOVA.

LEARNING OBJECTIVES

· Analyze the use of 
t-tests, ANOVA, and inferential statistics in research and evidence-based practice

· Evaluate strengths and weaknesses of inferential statistics in supporting evidence-based practice

· Interpret results and output from t-tests and ANOVA

· Summarize ANOVA Statistics

DISCUSSION: T-TESTS AND ANOVA IN CLINICAL PRACTICE

You are the DNP-prepared nurse responsible for overseeing staffing for the telehealth services provided at your practice. To determine the number of nurses that you might need for these services, you must determine how many patients might be interested in using the telehealth services versus the traditional clinical practice setting. For a week, you ask each patient visiting the practice his or her interest in setting up a visit via telehealth services. At the conclusion of the week, you use this data and reasoning to develop a statistic of the population interested in telehealth services. You have successfully used inferential statistics to help guide your decision-making for your practice.

The scenario outlined provides a random sampling and assumptions to develop a conclusion. With assumptions, and in this case, a small random sampling, this scenario is ripe with the possibility of error. However, how might inferential statistics be used in a valid and credible way? 

The design of a study determines the validity of the results, and if done following appropriate techniques, inferential statistics can determine clear differences and help researchers to form conclusions. In your Discussion, you will focus on two forms of identifying differences in groups: t-tests and analysis of variance (ANOVA).
For this Discussion, review the Learning Resources and reflect on a healthcare issue of interest to find a research article in which to analyze the use of inferential statistical analysis. Reflect on how the study was comprised, the validity of the findings, and whether or not it increased the study’s application to EBP

RESOURCES

LEARNING RESOURCES

Required Readings

· Gray, J. R., & Grove, S. K. (2020). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (9th ed.). Elsevier.

·

· Chapter 25, “Using Statistics to Determine Differences” (pp. 687–698)

· Donovan, L. M., & Payne, C. L. (2021). 
Organizational commitment of nurse faculty teaching in accelerated baccalaureate nursing programs.
Links to an external site.
 Nursing Education Perspectives,42(2), 81–86. doi:10.1097/01.NEP.0000000000000764

· Gray, J. A., & Kim, J. (2020). 
Palliative care needs of direct care workers caring for people with intellectual and developmental disabilities
Links to an external site.
. British Journal of Learning Disabilities, 48(1), 69–77. doi:10.1111/bld.12318

· Hilvert, E., Hoover, J., Sterling, A., & Schroeder, S. (2020). 
Comparing tense and agreement productivity in boys with fragile X syndrome, children with developmental language disorder, and children with typical development
Links to an external site.
. Journal of Speech, Language and Hearing Research, 63(4), 1181–1194. doi:10.1044/2019_JSLHR-19-00022  

· Document: 
Week 5 ANOVA Exercises SPSS Output 
 Download Week 5 ANOVA Exercises SPSS Output(PDF)

TO PREPARE:

· Consider some of the important issues in healthcare delivery or nursing practice today. Bring to mind the topics to which you have been exposed through previous courses in your program of study, as well as any news items that have caught your attention recently. Select one topic to focus on for this Discussion.

· Review journal, newspaper, and/or internet articles that may provide credible information on your selected topic. Then, select one research article to focus on for this Discussion that used inferential statistical analysis (either a -test or ANOVA) to study the topic.

· With information from the Learning Resources in mind, evaluate the purpose and value of the research study discussed in your selected article and consider the following questions:

· Who comprised the sample in this study?

· What were the sources of data?

· What inferential statistic was used to analyze the data collected (-test or ANOVA)?

· What were the findings?

· Ask yourself: How did using an inferential statistic bring value to the research study? Did it increase the study’s application to evidence-based practice?

BY DAY 3 OF WEEK 5

Post a brief description of the topic that you selected for this Discussion. Summarize the study discussed in your selected research article and provide a complete APA citation. Be sure to include a summary of the sample studied, data sources, inferential statistic(s) used, and associated findings. Then, evaluate the purpose and value of this particular research study to the topic. Did using inferential statistics strengthen or weaken the study’s application to evidence-based practice? Why or why not? Be specific and provide examples.

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JSLHR

Research Article

aWaisman Ce
bDepartment
Amherst
cDepartment
of Wisconsin–

Corresponden

Editor-in-Chi
Editor: Jan de

Received June
Revision rece
Accepted Dec
https://doi.org

Journ

D

Comparing Tense and Agreement
Productivity in Boys With Fragile X

Syndrome, Children With Developmental
Language Disorder, and Children

With Typical Development

Elizabeth Hilvert,a Jill Hoover,b Audra Sterling,a,c and Susen Schroedera

Purpose: This study compared and characterized the tense
and agreement productivity of boys with fragile X syndrome
(FXS), children with developmental language disorder (DLD),
and children with typical development (TD) matched on
mean length of utterance.
Method: Twenty-two boys with FXS (Mage = 12.22 years),
19 children with DLD (Mage = 4.81 years), and 20 children with
TD (Mage = 3.23 years) produced language samples that were
coded for their productive use of five tense markers (i.e.,
third-person singular, past tense –ed, copula BE, auxiliary BE,
and auxiliary DO) using the tense and agreement productivity
score. Children also completed norm-referenced cognitive
and linguistic assessments.
Results: Children with DLD generally used tense and
agreement markers less productively than children with TD,

nter, University of Wisconsin–Madison
of Communication Disorders, University of Massachusetts

of Communication Sciences and Disorders, University
Madison

ce to Elizabeth Hilvert: [email protected]

ef: Sean M. Redmond
Jong

21, 2019
ived September 16, 2019
ember 19, 2019
/10.1044/2019_JSLHR-19-00022

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particularly third-person singular and auxiliary BE. However,
boys with FXS demonstrated a more complicated
pattern of productivity, where they were similar to
children with DLD and TD, depending on the tense
marker examined. Results revealed that children
with DLD and TD showed a specific developmental
sequence of the individual tense markers that aligns
with patterns documented by previous studies, whereas
boys with FXS demonstrated a more even profile of
productivity.
Conclusions: These findings help to further clarify areas
of overlap and discrepancy in tense and agreement
productivity among boys with FXS and children with
DLD. Additional clinical implications of these results are
discussed.

S trong language skills are necessary for communicat-
ing effectively with others and have downstream
consequences for academic, cognitive, and social–

emotional outcomes (e.g., Johnson et al., 2010). Yet, delays
or impairments in language development are common among
children with various neurodevelopmental disorders. As a
result, there has been a burgeoning area of research aimed
at identifying the unique language profiles of clinical groups.
Empirical studies of this kind have significant clinical and

theoretical implications in that they provide a greater under-
standing of the language processes that are impacted by
disorders of known and unknown etiology. Despite varying
underlying origins, studies of children with neurodevelop-
mental disorders such as developmental language disorder
(DLD)1 and fragile X syndrome (FXS) point to similar
difficulties with grammar. In particular, the current study
will focus on finiteness.

Finiteness is a dimension of grammar that is at the
intersection of morphology and syntax as it involves

Disclosure: The authors have declared that no competing interests existed at the time
of publication.

1DLD is also referred to as specific language impairment (SLI). However,
SLI has stricter exclusionary criteria (i.e., a nonverbal IQ standard score
of 85 or above) compared to DLD (i.e., a nonverbal IQ standard score
of 70 or above). Many, but not all, studies in the literature that are now
referring to children as having DLD would have previously described
children as having SLI. The children included in this study meet criteria
for both DLD and SLI and have been referred to as having SLI in
previous studies by the authors. The classification of DLD was used in
order to align with the current literature (see Bishop et al., 2017).

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marking tense and agreement on verbs (e.g., third-person
singular –s, past tense –ed). Tense marking ability has long
been considered a robust clinical marker of DLD (Rice &
Wexler, 1996), and comparative studies have documented
similar difficulties with tense marking in other concomitant
disorders, including autism spectrum disorder (ASD) and
Down syndrome (e.g., Eadie et al., 2002; Laws & Bishop,
2003; Tager-Flusberg, 2006). Recent evidence also points to
deficits in tense marking for children with FXS (Estigarribia
et al., 2011; Price et al., 2008; Sterling, 2018; Sterling et al.,
2012), though it is less clear the extent to which precise
patterns of tense marking may overlap with those seen in
children with DLD (Haebig et al., 2016). Thus, the goal of
this study was to gain a more comprehensive understanding
of the similarities and differences in tense marking in chil-
dren with FXS and DLD compared to a group of children
with typical development (TD).

Tense Marking in Children With DLD and FXS
DLD is one of the most common pediatric language

disorders (Norbury et al., 2016; J. B. Tomblin et al., 1997;
also see Bishop et al., 2017, for a review). Prevalence esti-
mates indicate that approximately 7% of U.S. children start-
ing school present with DLD (J. B. Tomblin et al., 1997).
Children with DLD demonstrate language deficits in the
absence of hearing impairments, intellectual disability, or
neurological impairments (Leonard, 2014). As mentioned
above, difficulties mastering tense marking are well docu-
mented in young children with DLD, and these difficulties
are typically greater than general delays in vocabulary and
utterance length (i.e., measured via mean length of utter-
ance [MLU]; e.g., Rice et al., 2009; Rice & Wexler, 1996,
Rice et al., 1998). More specifically, children with DLD
frequently omit tense markers in everyday speech (e.g., she
run) and show delays in the use or mastery of these mor-
phemes in experimental production tasks (Rice & Wexler,
1996, 2001; Rice et al., 1998). The omission of tense markers
is persistent in DLD. For example, in a series of studies,
Rice and Wexler (1996, 2001) found that less than 10% of
5-year-olds with DLD had mastered tense marking com-
pared to at least 80% of 5-year-olds with TD.

Although delays in the mastery of tense marking are
considered a hallmark feature of DLD, they are not lim-
ited to children with DLD. This has motivated comparative
studies between DLD and other neurodevelopmental disor-
ders that have noted areas of commonality as well as some
distinctions in tense development (Eadie et al., 2002; Haebig
et al., 2016; Laws & Bishop, 2003; J. A. Roberts et al., 2004).
These findings have contributed to the ongoing debate as to
whether similar developmental processes may be perturbed
in these disorders that lead to overlapping language difficul-
ties (Ellis Weismer, 2013; B. Tomblin, 2011). Among these
comparison studies, one disorder that has received limited
attention is FXS, despite children also presenting with weak-
nesses in finiteness. Therefore, examining whether children
with FXS may demonstrate a similar or distinct tense marking

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profile compared to children with DLD is important for
shedding further light on this debate.

FXS is the leading inherited cause of intellectual dis-
ability, which affects around one in 2,500–4,000 boys and
one in 8,000 girls (Crawford et al., 2001; Fernandez-Carvajal
et al., 2009). It is the result of a single gene (FMR1) muta-
tion on the X chromosome (Verkerk et al., 1991), which
disrupts the production of a protein that is necessary for nor-
mal brain development. As a result, individuals with FXS
often present with language impairments, hyperactivity,
and social anxiety, in addition to an intellectual disability
(Cordeiro et al., 2011; Sterling et al., 2012; Sullivan et al.,
2006). A substantial number of individuals with FXS also
demonstrate behaviors similar to those with ASD, with ap-
proximately 27%–75% receiving a co-diagnosis of ASD
(Clifford et al., 2007; Klusek et al., 2014). Given the X-linked
nature of FXS, not only are diagnoses of ASD more com-
mon in males, but males are generally more severely affected
than females (Hagerman & Hagerman, 2002). Thus, in this
study, we focused on boys with FXS in order to control for
sex differences commonly observed for children with FXS.

A number of studies have indicated that boys with
FXS demonstrate delays in grammar, beyond what would be
expected given their nonverbal mental age (e.g., Estigarribia
et al., 2011; Finestack et al., 2013; Martin et al., 2013; Price
et al., 2008). More specifically, boys with FXS demonstrate
significantly shorter conversational MLU compared to
children with TD matched on nonverbal mental age (e.g.,
Finestack et al., 2013; Kover et al., 2012). Others have also
found that nonverbal mental age–matched boys with TD
outperform boys with FXS in their use of noun phrases,
verb phrases, and sentence structure (Price et al., 2008; J. E.
Roberts et al., 2007). Although limited, a growing body of
research has begun to specifically examine the tense marking
abilities of boys with FXS. For example, Estigarribia et al.
(2011) found that boys with FXS produced fewer total mor-
phosyntactic verbs that marked tense in conversational lan-
guage samples than boys with TD, after controlling for
nonverbal mental age, maternal education, and articulation.

Sterling and colleagues (Haebig et al., 2016; Sterling,
2018; Sterling et al., 2012) extended this work by examin-
ing tense marking at a more detailed level, evaluating per-
formance on specific types of tense markers using the Test
of Early Grammatical Impairment (TEGI; Rice & Wexler,
2001). The TEGI is a norm-referenced assessment that is
designed to elicit tense markers in an obligatory context
and has probes that assess third-person singular, past tense
(regular and irregular), as well as copula and auxiliary BE
and auxiliary DO verbs. Sterling (2018) compared the tense
marking abilities of boys with FXS to boys with idiopathic
ASD who were similar in terms of ASD severity and MLU.
Both groups of boys demonstrated a strength in their accu-
rate use of third-person singular and copula and auxiliary
BE, but they had a relative weakness with regular past tense
and auxiliary DO morphemes. This pattern is interesting
considering the typical developmental course or emergence
of these morphemes (Stage III: copula BE; Stage IV: past
tense –ed and third-person singular; and Stage V: auxiliary

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BE and DO; Brown, 1973). In any case, boys with FXS
demonstrated greater difficulty producing auxiliary BE
verbs on the TEGI than boys with idiopathic ASD. This
is noteworthy as research has indicated that at least a sub-
set of children with ASD has deficits in the use of tense
and agreement marking (J. A. Roberts et al., 2004; Tager-
Flusberg, 2006). Sterling and colleagues also evaluated
the tense marking abilities of boys with FXS in relation to
other aspects of their language and found that tense mark-
ing performance was below receptive vocabulary expecta-
tions specifically for third-person singular and past tense
morphemes (Sterling et al., 2012). However, their overall
tense marking performance exceeded expectations bench-
marked to MLU. This latter finding suggests that boys
with FXS may demonstrate a unique profile compared to
children with DLD, as tense marking ability is dispropor-
tionally poorer than general delays in MLU in children
with DLD (e.g., Hoover et al., 2012; Leonard et al.,
1992).

However, to our knowledge, only one study has di-
rectly compared the grammatical abilities of boys with
FXS to children with DLD. Using the TEGI, Haebig et al.
(2016) found, as expected, that comparisons to the norma-
tive scores in the TEGI manual indicated that the boys with
FXS generally performed below nonverbal mental age ex-
pectations (Rice et al., 2010). However, the boys with FXS
were significantly better on all tense marker probes com-
pared to younger, MLU-matched children with DLD. In
line with the results of Sterling et al. (2012), boys with FXS
instead performed similarly to MLU-matched children
with TD on the TEGI and even outperformed the children
with TD on third-person singular productions. Together,
these studies provide an initial profile of tense marking abil-
ity in FXS—that is, tense marking abilities appear to be in
line with MLU expectations and exceed the performance
of younger children with DLD, but these previous studies
have primarily relied on information from norm-referenced
tests. Extending this comparison between children with
FXS and DLD using other types of assessment, particularly
those derived from spontaneous language, is essential in or-
der to explore the differentiation between the grammatical
phenotypes of these clinical groups.

Methods for Assessing Tense Marking
It is important to consider the type of language as-

sessments that are being utilized as varying techniques have
different intrinsic properties and tap into different dimen-
sions of the same construct (e.g., tense marking accuracy vs.
production). Understanding these subtle nuances can pro-
vide a deeper understanding of language performance and
the degree to which it appears to be impaired (e.g., Kover
et al., 2012). With regard to tense marking, assessment
methods generally fall into two categories: (a) those that
explicitly target the comprehension or production of tense
markers through either experimentally designed probes or
norm-referenced measures and (b) those that assess spon-
taneous tense marking using language samples. The TEGI

Hilvert

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is one example of a norm-referenced assessment. Children’s
performance on tense marker probes is measured by accuracy,
which can be compared to a normative sample. Because
this has been previously used to evaluate tense marking
in FXS, we were interested in using the latter method—
examining spontaneous production of tense marking in a
language sample. The aim of doing so was to gain a deeper
understanding of tense marking, beyond accuracy, by exam-
ining tense production in boys with FXS and how it com-
pares to children with DLD and TD.

When evaluating tense marking using language sam-
ples, researchers will often use composite scores that examine
the productive use of tense and agreement. These include
measures such as the finite verb morphology composite
(Leonard et al., 1999), the tense composite (Rice et al., 1998),
and the tense and agreement productivity (TAP) score
(Hadley & Short, 2005). The finite verb morphology com-
posite and the tense composite are similar in that they both
provide a combined percentage of tense/agreement mor-
phemes used in obligatory contexts. Although both scores
provide valuable information, one problem that has been
identified with using these composites is that children re-
ceive credit for each use of the morphemes of interest, in-
cluding tense markers that appear in high-frequency and
potentially memorized morpheme combinations (e.g., it’s,
that’s). As such, these composite scores may overestimate a
child’s tense marking abilities.

For this reason, we used the TAP score in this study.
The TAP score was designed to examine tense marking in
“diverse, low frequency sentences frames” as a way to pro-
vide an accurate estimate of the productivity or depth of
the tense and agreement system early on in development
(Rispoli & Hadley, 2018, p. 1457). It is computed by iden-
tifying children’s productive use of (a) third-person sin-
gular (e.g., he walks), (b) regular past tense –ed (e.g., she
flipped ), (c) copula BE (e.g., the boy is sleepy), (d) auxil-
iary BE (e.g., he is getting out), and (e) auxiliary DO (e.g.,
do they eat carrots?). However, there are specific productiv-
ity criteria to protect against artificially inflated scores.
Children are only able to receive a maximum of 5 points
for each tense marker when using it in up to five sufficiently
different syntactic contexts. To be considered sufficiently
different, third-person singular and past tense –ed forms must
occur on different verbs (e.g., wanted, looked ), whereas
copula BE, auxiliary BE, and auxiliary DO must occur with
different sentence subjects (e.g., The boy is sleepy; The girl
is at the mall). Moreover, to further reduce the chance of
overestimating tense mastery, all instances in which con-
tracted copula or auxiliary BE appears with pronoun sub-
jects (e.g., it’s, that’s) are excluded.

In their initial study, Hadley and Short (2005) were
able to differentiate 2-year-old children at risk for DLD
from children with low-average language abilities using the
TAP score. More recently, research has shown that the
TAP score is also able to distinguish the tense marking abili-
ties of older, preschool-age children with DLD and age-
matched children with TD (Gladfelter & Leonard, 2013;
Guo & Eisenberg, 2014). Hadley and Short found that

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copula BE and third-person singular were the first forms to
emerge and were most consistently productive. Finally,
the TAP score is highly correlated with other measures of
expressive vocabulary and grammar taken from language
samples (i.e., number of different words [NDW], MLU,
Index of Productive Syntax; Hadley & Short, 2005).

Overview of This Study
The current study extends previous research by com-

paring and characterizing the tense and agreement produc-
tivity of boys with FXS and MLU-matched children with
DLD and TD using spontaneous language samples. We
were interested not only in examining differences between
these three groups in terms of productivity as measured by
the TAP score but also in examining the pattern of produc-
tivity across individual tense and agreement morphemes
within each clinical group. This was motivated by the fact
that there is still limited understanding of the pattern of
tense and agreement emergence in children with FXS in
particular, compared to what we know about children with
TD and DLD. Moreover, though the TAP score is related
to other conversational measures of expressive grammar
(Hadley & Short, 2005), research is needed to understand
how the TAP score may be correlated to norm-referenced
measures of tense marking, such as the TEGI. We were
also interested in examining the association between tense
productivity and lexical diversity (i.e., NDW) in order to
explore whether children’s expressive grammar ability aligned
with their expressive vocabulary ability. Thus, our research
questions were the following: (a) Do boys with FXS, chil-
dren with DLD, and children with TD all matched on MLU
differ in their tense and agreement productivity (i.e., total
productivity, productivity of specific tense markers)? (b) Are
children using certain types of tense markers more produc-
tively than others, and does this pattern differ across the
three groups? (c) Is the tense and agreement productivity of
children with FXS, DLD, and TD related to their perfor-
mance on other measures of expressive language (i.e., NDW,
MLU, and the TEGI)?

Based on previous findings (Haebig et al., 2016;
Sterling et al., 2012), we expected that the boys with FXS
would produce more sufficiently different tense and agree-
ment markers than MLU-matched children with DLD,
and instead look similar to MLU-matched children with
TD. We also expected that boys with FXS would demon-
strate a pattern of productivity that more closely aligned
with that of children with TD than that of children with
DLD. However, it is possible that our findings may not
simply mirror those of previous studies given that a dif-
ferent assessment technique is being used in the current
study (language sampling vs. the TEGI). In particular,
language sampling draws more heavily on pragmatics,
which may present a particular challenge for the boys
with FXS. Thus, we alternatively hypothesized that the
boys with FXS could look more similar to the MLU-
matched children with DLD than the children with TD
when assessing tense marking via language sampling. In

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support of this, Finestack et al. (2013) found that boys
with FXS did not differ from nonverbal mental age–
matched peers with TD on a standardized measure of ex-
pressive grammar, but the boys with FXS did have lower
MLUs. Finally, we predicted that expressive vocabulary
(NDW) and grammar (MLU, TEGI) would be associated
with children’s TAP scores, with a similar pattern of associ-
ations found across the three groups.

Method
Participants

The study included 61 children: 22 with FXS, 19 with
DLD, and 20 with TD. The children with FXS were a
subsample of participants from a larger study examining
grammar and language assessment (Friedman et al., 2018;
Haebig & Sterling, 2017; Haebig et al., 2016; Sterling, 2018).
The children with TD and DLD participated in a larger
study focused on identifying factors influencing the omis-
sion of finiteness markers (Hoover et al., 2012). All chil-
dren were monolingual speakers of Standard American
English. All parents provided written informed consent, and
children provided assent. Study procedures were approved
by the institutional review boards.

The children with FXS were all boys who had the
full mutation, confirmed via previous genetic testing. All
boys with FXS met ASD criteria on both the Autism Diag-
nostic Observation Schedule (or Autism Diagnostic Obser-
vation Schedule–Second Edition; Lord et al., 1999, 2012)
and the Autism Diagnostic Interview–Revised (Rutter
et al., 2003), a caregiver-based interview of children’s past
and present behaviors. The children with DLD included
12 boys and seven girls. The presence of DLD was con-
firmed either by an existing diagnosis of language impair-
ment by a speech-language pathologist or by performance
below age expectations on MLU and the elicited grammar
composite of the TEGI (Rice & Wexler, 2001). All children
with DLD had normal intellectual abilities, confirmed by
scores on a test of nonverbal IQ (Reynolds Intellectual
Assessment Scales [RIAS]; Reynolds & Kamphaus, 2003),
and normal hearing ability. Though all of the children with
DLD performed below age expectations for MLU and the
TEGI, only some also had significant weaknesses in vocab-
ulary (see receptive vocabulary scores in Table 1). Children
with TD included eight boys and 12 girls that scored within
the normal range on the complete diagnostic testing battery
(TEGI, MLU, Peabody Picture Vocabulary Test–Fourth
Edition, and RIAS) and had normal hearing ability.

Group Comparisons
Participants with FXS, DLD, and TD were well

matched on MLU, F(2, 58) = 0.64, p = .529, ηp
2 = .02,

following the conventions set forth in Kover and Atwood
(2013). MLU-based comparisons are common in studies of
children with neurodevelopmental disorders (e.g., Haebig
et al., 2016; Levy et al., 2006; Rice et al., 1998; Sterling,
2018). MLU is a robust index of language acquisition.

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Table 1. Participant characteristics.

Variable FXS (n = 22) DLD (n = 19) TD (n = 20)

Chronological age 12.22 (1.98) 4.81 (0.65) 3.23 (0.26)
Nonverbal cognition (standard score)a 47.68 (8.48) 111.68 (16.20) 116.47 (12.65)
Nonverbal mental age equivalencea 5.32 (0.65) 5.27 (1.10) 4.14 (0.59)
MLU in morphemes 3.79 (1.03) 3.99 (0.73) 4.08 (0.77)
NDW 128.68 (24.62) 111.32 (19.89) 113.90 (20.21)
Racial identity
White 91.0% 73.7% 95.0%
African American 0.0% 15.8% 5.0%
Other 4.5% 0.0% 0.0%
More than one race 4.5% 10.5% 0.0%

Ethnic identity
Not Hispanic/Latino 85.7% 94.7% 100%
Hispanic/Latino 14.3% 5.3% 0.0%

TEGI elicited grammar compositeb 70.68 (16.82) 29.00 (14.80) 61.63 (8.90)
Receptive vocabulary (standard score)c 61.45 (14.72) 95.84 (11.51) 112.70 (10.55)

Note. FXS = fragile X syndrome; DLD = developmental language disorder; TD = typical development; MLU = mean length of utterance;
NDW = number of different words.
aLeiter International Performance Scale–Revised (Roid & Miller, 1997) or Reynolds Intellectual Assessment Scales (Reynolds & Kamphaus, 2003).
bTest of Early Grammatical Impairment (TEGI; Rice & Wexler, 2001). cPeabody Picture Vocabulary Test–Fourth Edition (Dunn & Dunn, 2007).

Moreover, MLU-based comparisons help control for im-
portant confounds (e.g., utterance length) and allow for
findings to be evaluated within the broader literature on
tense marking.

In terms of nonverbal mental age, overall, the groups
differed significantly, F(2, 58) = 14.00, p = .0001, ηp

2 = .33.
Follow-up independent-samples t tests with Holm–Bonferroni
corrections revealed that children with TD had a younger
nonverbal mental age equivalence compared to children
with DLD, p = .0003, and boys with FXS, p = .0003. How-
ever, when comparing the two clinical groups, the children
with DLD and boys with FXS were well matched, p = .866.
This difference in nonverbal mental age equivalence be-
tween children with DLD and TD is not surprising, as these
groups were initially matched on MLU, and to do so, the
children with TD were chronologically younger. As expected,
there was also a significant difference in children’s nonverbal
IQ standard scores, F(2, 58) = 192.77, p = .0001, ηp

2 = .87,
with boys with FXS having significantly lower scores com-
pared to children with TD, p = .0003, and children with
DLD, p = .0003. Importantly, the children with DLD and
TD were similar in terms of their nonverbal IQ standard
scores, p = .316. See Table 1 for additional information.

Materials
Nonverbal IQ

Two different assessments of nonverbal cognition
were used. The children with FXS completed the Leiter
International Performance Scale–Revised (Roid & Miller,
1997). The children with DLD and the children with TD
completed the two subtests from the Nonverbal Intelli-
gence Index of the RIAS (Reynolds & Kamphaus, 2003).
Standard scores and mental age equivalence scores were
calculated for each assessment.

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Language Assessments
The Peabody Picture Vocabulary Test–Fourth Edition

(Dunn & Dunn, 2007) is a norm-referenced assessment of
vocabulary comprehension that was used to describe the
participants. The TEGI (Rice & Wexler, 2001) was admin-
istered to assess children’s expressive grammatical abilities.
The TEGI is a clinical tool that is used for the screening,
identification, and diagnosis of grammatical impairments
in children between 3 and 8 years old. The TEGI specifi-
cally examines finite verb morphology. Although the TEGI
has been used primarily to evaluate language abilities in
children with DLD (e.g., Hoover et al., 2012; Rice & Wexler,
2001), it has also been used with children with FXS (Haebig
et al., 2016; Sterling, 2018; Sterling et al., 2012). Prior to
evaluating grammar ability, the phonological probe of
the TEGI was administered to ensure that children were
able to correctly produce the phonemes that are required
to produce finiteness markers (i.e., /s/, /z/, /t/, /d/ ) in mono-
morphemic words (e.g., “bus,” “cheese,” “hat,” “bed”). All
children passed the phonological probe by demonstrating
accurate production of the relevant phonemes and were sub-
sequently administered the three probes that comprise the
elicited grammar composite: third-person singular, past
tense (regular and irregular), and BE/DO (copula BE and
auxiliary BE and DO). For these subtests, a prompt is pro-
vided that elicits a sentence containing an obligatory con-
text for each given tense marker. Responses are scored as
correct, incorrect, or unscorable. Responses are incorrect if
the child omits the finiteness marker. A response is unscor-
able when a child produces a nontarget tense (e.g., past
tense during third-person singular probe) or a nontarget
subject (e.g., plural subject in third-person singular probe)
within a particular subtest. The TEGI does not include
unscorable responses when calculating children’s accuracy.
Therefore, the elicited grammar composite reflects the per-
centage of correct responses out of total scorable responses.

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Language Samples
Prior research suggests that conversational sampling

during play-based activities is the most appropriate method
for eliciting a language sample from young children, whereas
a semistructured interview is considered to be more appro-
priate for eliciting a conversational language sample from
older, school-age children (e.g., Evans & Craig, 1992;
Haebig et al., 2016; Miller, 1981). Moreover, studies com-
paring language sampling contexts suggest that more com-
plex grammar may be elicited from less structured, play-
based situations in young children, whereas more complex
grammar is elicited from interview-style conversations in
school-age children (Evans & Craig, 1992; Longhurst &
File, 1977; Southwood & Russell, 2004; Westerveld et al.,
2004). Thus, in line with prior research (Haebig et al., 2016),
we selected sampling procedures that were considered age
appropriate for each group considering both chronological
and mental age in order to elicit comparable MLU—boys
with FXS completed a 10-min conversation-based language
sample, and the children with DLD and TD completed a
30-min play-based language sample. In the semistructured
conversation sample, we followed the procedures devel-
oped by Berry-Kravis et al. (2013), which were created for
obtaining language samples from children with FXS. The
examiner followed a list of conversation topics, starting
with the participant’s specific interest and moving to a set
list of topics (e.g., sports, pets, school). The examiner used
elicitation techniques (e.g., open-ended questions) to en-
courage the child to talk, while at the same time minimiz-
ing their own talk (Berry-Kravis et al., 2013). During the
play-based sample, the examiner and child played with
age-appropriate toys, and the examiner engaged in toy talk
with the child, which, for younger children, is an effective
method of eliciting utterances that should be marked for
tense and agreement (Hadley & Walsh, 2014).

Children’s language samples were transcribed using
the Systematic Analysis of Language Transcripts (SALT)
procedures (Miller et al., 2011) by trained and reliable un-
dergraduate and graduate student coders. Utterances were
segmented according to C-units, that is, an independent
clause and all attached subordinate clauses. MLU in mor-
phemes and NDW were generated using SALT and were
based on complete and intelligible utterances.

TAP Scoring
Children’s language transcripts were coded for their

use of tense markers using the TAP score (Hadley & Short,
2005). The TAP score is computed by identifying children’s
productive use of (a) third-person singular present tense,
(b) regular past tense –ed, (c) copula BE, (d) auxiliary BE,
and (e) auxiliary DO. Children earned a score between 0
and 5 for each morpheme, with 1 point awarded for each
sufficiently different use of the morpheme. Across the full
set of morphemes, the total tense productivity score ranged
from 0 to 25, with higher scores indicating higher levels of
tense and agreement morpheme productivity in unique
syntactic contexts. To be considered a sufficiently different
use, correct uses of third-person singular and regular past

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tense –ed had to occur with different lexical verbs (e.g., She
needed help; The dog dropped the ball). For the regular past
tense –ed score, overregularization of the verb inflection
(e.g., goed ) was counted as correct, but all other errors
were not considered correct (e.g., the children plays with
the ball). Correct productions of copula BE, auxiliary BE,
and auxiliary DO were counted in the score as long as they
occurred with different sentence subjects (e.g., the boy is
small; the girl is loud). For copula and auxiliary BE, all
sentences that had contracted pronominal subjects (e.g.,
she’s finished) or wh-words (e.g., what’s that sound?) were
excluded to avoid the possibility of overcrediting poten-
tially unanalyzed, lexically specific forms. For specific ex-
amples of TAP coding, see the Appendix.

Given that the duration of language sampling proce-
dures differed for boys with FXS and children with DLD
and TD, for the purpose of calculating the TAP score, as
well as MLU and NDW, the first 100 utterances were
selected from children’s language samples. This allowed us
to equate the sample size from which tense markers were
obtained. Additionally, the first 100 utterances were selected
because research has shown that TAP scoring on 100 utter-
ance samples has better diagnostic accuracy than scores
from 50 utterance samples (Guo & Eisenberg, 2014).

Reliability
SALT Reliability

For reliability coding, we randomly selected five boys
with FXS (23%), four children with DLD (21%), and four
children with TD (20%) and had a second trained coder
independently transcribe these language samples in SALT.
Interobserver word agreement was 83% for boys with FXS,
90% for the children with DLD, and 90% for the children
with TD. Interobserver agreement for the presence or
absence of bound morphemes was 81% for the FXS group,
89% for the DLD group, and 89% for the TD group.

TAP Reliability
A second independent coder completed TAP score

coding for five boys with FXS (23%), four children with
DLD (21%), and four children with TD (20%). When ex-
amining productive and unproductive uses of tense and
agreement, interobserver agreement was 94% for past tense
–ed, 97% for third-person singular, 89% for copula BE,
97% for auxiliary BE, and 92% for auxiliary DO.

Data Analysis
Question 1

To address our first question, we ran a one-way anal-
ysis of variance (ANOVA) to explore group differences on
the TAP total score and a multivariate analysis of variance
(MANOVA) to assess group differences on the five indi-
vidual tense markers, that is, third-person singular, past
tense -ed, copula BE, auxiliary BE, and auxiliary DO. In
both analyses, diagnostic group was the fixed factor. Main
effects of diagnostic group were followed up with planned

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Table 2. Comparison of tense and agreement productivity scores
across groups.

Variable FXS DLD TD

Copula BE 3.23 (1.63) 3.00 (1.49) 3.00 (1.41)
Third-person singular 1.95 (1.81)b 2.11 (1.33)c 3.55 (1.50)b,c

Past tense –ed 1.23 (1.41) 0.58 (1.07) 1.05 (1.05)
Auxiliary BE 0.91 (0.97) 0.68 (0.89)c 1.75 (1.41)c

Auxiliary DO 1.41 (1.44)a 0.42 (0.77)a 0.70 (0.87)
Total score 8.77 (3.73) 6.79 (3.01)c 10.10 (2.43)c

Note. Standard deviation in parentheses. FXS = fragile X syndrome;
DLD = developmental language disorder; TD = typical development.
aSignificant difference between FXS and DLD. bSignificant
difference between FXS and TD. cSignificant difference between
DLD and TD.

t tests, using a Holm–Bonferroni correction to adjust for
multiple comparisons (Holm, 1979).

Because there was a significant difference in nonver-
bal IQ between boys with FXS and children with DLD
and TD, and a significant difference in nonverbal mental
age between children with TD and children with DLD and
FXS, both variables were initially considered as covariates.
Correlation analyses were completed to examine the rela-
tion between nonverbal IQ, nonverbal mental age, and the
dependent variables. The analyses revealed that both non-
verbal IQ (standard score) and nonverbal mental age were
not correlated with any of the dependent variables for boys
with FXS, r(20) ≤ .35, ps ≥ .140; children with DLD,
r(17) ≤ .37, ps ≥ .125; and children with TD, r(18) ≤ −.35,
ps ≥ .142. Given the lack of significant correlations, we
chose not to include these factors as covariates. Addition-
ally, a number of methodological and theoretical concerns
regarding the use of nonverbal IQ as a covariate have been
outlined by Dennis et al. (2009). Specifically, adjusting for
nonverbal IQ in clinical populations such as FXS makes
interpretation of results difficult, given that intellectual
disability is a central part of the disorder (Dennis et al.,
2009). Similarly, despite boys with FXS being older than
the children with DLD and TD, chronological age was
also not related to any of the dependent variables in boys
with FXS, r(20) ≤ .32, ps ≥ .150, and children with TD,
r(18) ≤ −.32, ps ≥ .171, and only related to the production
of copula BE in children with DLD, r(17) = .49, p = .033.
Thus, we chose not to control for chronological age.

Question 2
Research question two examined the pattern of tense

and agreement productivity within each group. We com-
pleted separate repeated-measures ANOVAs for each diag-
nostic group. The within-subject variable was tense type
(third-person singular, past tense –ed, copula BE, auxiliary
BE, auxiliary DO). Main effects of tense type were followed
up with t tests, using a Holm–Bonferroni correction to
adjust for multiple comparisons (Holm, 1979).

Question 3
For our third research question, Pearson correlations

were completed to determine whether children’s TAP total
scores were related to NDW, MLU, and the elicited gram-
mar composite score on the TEGI. Separate correlations
were run for each diagnostic group.

Results
Question 1: Differences Between FXS, DLD,
and TD in TAP Performance

ANOVA analyses revealed a significant effect of di-
agnostic group for the TAP total score, F(2, 58) = 5.52,
p = .006, ηp

2 = .16 (see Table 2). Follow-up independent-
samples t tests with Holm–Bonferroni corrections showed
that children with DLD scored lower on their overall TAP
performance than children with TD, t(37) = 3.79, p = .003,

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but their performance did not differ from boys with FXS,
t(39) = 1.85, p = .140. Boys with FXS also did not differ
from children with TD, t(40) = 1.35, p = .184. When exam-
ining the use of individual tense markers, the MANOVA
revealed a significant main effect of diagnostic group on
tense production, F(10, 110) = 3.88, p = .0001, ηp

2 = .26.
Follow-up ANOVAs revealed a significant main effect
of diagnostic group for the use of third-person singular,
F(2, 58) = 6.36, p = .003, ηp

2 = .18; auxiliary BE, F(2, 58) =
5.07, p = .009, ηp

2 = .15; and auxiliary DO, F(2, 58) = 4.60,
p = .014, ηp

2 = .14. No main effect of diagnostic group was
found for copula BE, F(2, 58) = .16, p = .855, ηp

2 = .01, or
past tense –ed, F(2, 58) = 1.56, p = .219, ηp

2 = .05.
For third-person singular, follow-up analyses revealed

that children with DLD, t(37) = 3.17, p = .003, and boys
with FXS, t(40) = 3.09, p = .009, produced significantly
fewer unique instances of the morpheme compared to chil-
dren with TD. However, boys with FXS and children with
DLD did not differ from one another in their production
of third-person singular, t(39) = 0.29, p = .766. Similarly,
for auxiliary BE, children with DLD produced fewer dif-
ferent instances of auxiliary BE compared to children with
TD, t(37) = 2.81, p = .008. The clinical groups (FXS and
DLD) did not differ from one another in their use of auxil-
iary BE, t(39) = −0.77, p = .446. With regard to auxiliary
DO, children with DLD produced fewer instances of this
tense marker compared to boys with FXS, t(33.00) = −2.80,
p = .027, but did not differ from children with TD, t(36.85) =
1.07, p = .293. Moreover, boys with FXS did not differ
from children with TD in their use of auxiliary BE, t(40) =
2.27, p = .058, or auxiliary DO, t(34.94) = −1.96, p = .116.
See Table 2 for means and standard deviations for each
group.

Question 2: Patterns of Tense Productivity
in Children With FXS, DLD, and TD
Tense Marking in Boys With FXS

The repeated-measures ANOVA revealed a signifi-
cant main effect of tense marker type for boys with FXS,
F(4, 84) = 8.95, p = .0001, ηp

2 = .30. Follow-up paired-

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samples t tests with Holm–Bonferroni corrections revealed
children were more productive with their use of copula
BE than past tense –ed, t(21) = 4.87, p = .001; auxiliary
BE, t(21) = 6.39, p = .001; and auxiliary DO, t(21) =
4.57, p = .001. However, the productivity of copula BE
did differ from third-person singular, t(21) = 2.45, p = .161.
Moreover, no differences in the productivity or use of
the other four tense markers (i.e., third-person singular,
past tense –ed, auxiliary BE, and auxiliary DO) were found,
ts(21) ≤ 2.06, ps ≥ .312 (see Figure 1).

Tense Marking in Children With DLD
Analyses revealed a significant main effect of tense

marker type for children with DLD, F(4, 72) = 21.01,
p = .0001, ηp

2 = .56. Paired-samples t tests with Holm–

Bonferroni corrections revealed that children were more pro-
ductive in their use of copula BE than past tense –ed,
t(18) = 5.85, p = .0009; auxiliary BE, t(18) = 7.33, p = .0009;
and auxiliary DO, t(18) = 4.59, p = .0009. However, the
use of copula BE and third-person singular did not differ,
t(18) = 2.22, p = .160. Moreover, children with DLD used
third-person singular more productively than past tense –ed,
t(18) = 3.75, p = .005; auxiliary BE, t(18) = 4.47, p = .001;
and auxiliary DO, t(18) = 4.59, p = .001. No differences
were found though between children’s use of past tense –ed,
auxiliary BE, and auxiliary DO, ts(18) ≤ −1.16, ps ≥ .786
(see Figure 1).

Tense Marking in Children With TD
A main effect of tense marker type was also found

for children with TD, F(4, 76) = 21.01, p = .0001, ηp
2 = .54.

Figure 1. Pattern of tense and agreement productivity across groups. The
FXS = fragile X syndrome; DLD = developmental language disorder; TD =

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Follow-up paired-samples t tests with Holm–Bonferroni
corrections revealed that children with TD were significantly
more productive with copula BE than past tense –ed, t(19) =
6.35, p = .001, and auxiliary DO, t(19) = 6.19, p = .001.
Children with TD also used third-person singular more
productively than past tense –ed, t(19) = 6.35, p = .001;
auxiliary BE, t(19) = 3.39, p = .018; and auxiliary DO,
t(19) = 6.19, p = .001. Finally, children with TD were
more productive with auxiliary BE than auxiliary DO,
t(19) = −3.28, p = .020. No other significant differences
between tense markers were found for children with TD,
ts(19) ≤ 2.70, ps ≥ .056 (see Figure 1).

Question 3: Associations Between the TAP
Score and Measures of Expressive Vocabulary
and Grammar

As shown in Table 3, Pearson correlation analyses
revealed that TAP total scores were positively correlated to
NDW in boys with FXS and children with TD, but not
children with DLD. With regard to MLU, boys with FXS,
children with DLD, and children with TD with higher
TAP total scores had longer MLUs. However, regardless
of group, no significant associations were found between
the TAP total score and the TEGI composite score (see
Table 3).

Discussion
The grammatical system plays a fundamental role in

the ability to communicate effectively with others and in

solid line indicates the median, and the cross indicates the mean.
typical development.

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Table 3. Correlations between tense and agreement productivity
(TAP) total score and measures of expressive vocabulary and grammar.

Variable Boys with FXS

TAP total score

r p

NDW .70 .0001
MLU .70 .0001
TEGI elicited grammar composite .30 .172

Children with DLD

TAP total score

r p

NDW .26 .279
MLU .46 .048
TEGI elicited grammar composite .26 .278

Children with TD

TAP total score

r p

NDW .46 .043
MLU .74 .0001
TEGI elicited grammar composite −.071 .766

Note. FXS = fragile X syndrome; NDW = number of different
words; MLU = mean length of utterance; TEGI = Test of Early
Grammatical Impairment; DLD = developmental language disorder;
TD = typical development.

the development of academic skills such as reading and
writing. For this reason, deficits in grammar can lead to
lifelong difficulties, making it essential to determine the
extent to which impairments may be pervasive among dif-
ferent groups of children. Although impairments in grammar
have primarily been associated with DLD, there has been
a growing body of research that has demonstrated that
difficulties with grammar, and tense marking in particular,
may be present across a variety of neurodevelopmental
disorders, including FXS (Estigarribia et al., 2011; Sterling,
2018; Sterling et al., 2012). However, research comparing
children with FXS to children with DLD has been limited
and exclusively used norm-referenced assessments of tense
marking accuracy (i.e., the TEGI; Haebig et al., 2016).
Thus, the purpose of the current study was to extend this
work by comparing and characterizing the tense and
agreement productivity of boys with FXS and younger,
MLU-matched children with DLD and TD using lan-
guage samples. Moreover, this study compared children’s
pattern of tense marking and examined whether tense pro-
ductivity was related to other measures of expressive vo-
cabulary and grammar.

Comparison of Tense and Agreement Productivity
in FXS, DLD, and TD

When examining the total TAP score, our findings
revealed that children with DLD produced fewer overall

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tense and agreement markers than children with TD but
that they did not differ from boys with FXS. Moreover, boys
with FXS did not differ in their overall production of
tense and agreement morphemes compared to children with
TD. In other words, the overall tense marker production
of boys with FXS fell in an intermediate range between
children with DLD and TD, where the groups on the most
extreme ends of the continuum (DLD at the low end and
TD at the high end) differed from one another but not
from the boys with FXS. Nevertheless, analyses of the indi-
vidual tense markers revealed a slightly different and more
complicated pattern of tense marking across these three
groups. More specifically, boys with FXS and children with
DLD demonstrated similar levels of productivity for all
tense markers except auxiliary DO—children with DLD
used auxiliary DO in fewer unique syntactic contexts than
boys with FXS. Both boys with FXS and children with
DLD produced fewer instances of third-person singular
than younger, MLU-matched children with TD. Children
with DLD also produced fewer distinct instances of auxil-
iary BE than children with TD. Interestingly, no other
differences were found between any of the groups. There-
fore, children with TD used auxiliary DO as productively
as boys with FXS and children with DLD. Specifically, the
children with TD produced auxiliary DO at an intermedi-
ate level between boys with FXS, who used it the most,
and children with DLD, who used it the least. Additionally,
children across the three groups did not differ in their use
of copula BE or past tense –ed.

In some ways, this pattern of results aligns more
closely with our alternative hypothesis and contrasts from
the findings of Haebig et al. (2016), specifically in terms of
the differences they found between children with DLD and
FXS when using the TEGI to measure tense marking accu-
racy. In particular, Haebig et al. (2016) found that boys
with FXS were more accurate than younger, MLU-matched
children with DLD across all probes on the TEGI, not just
DO probes. Moreover, their analyses revealed that boys
with FXS were in line with younger, MLU-matched chil-
dren with TD on past tense, BE, and DO probes, and
actually outperformed children with TD on third-person
singular probes. This latter difference directly contradicts
the direction of our findings. Given these discrepancies,
it is important to consider that different assessment tech-
niques were used (language sampling vs. norm-referenced
assessment) and different dimensions of tense marking
were examined (productivity vs. accuracy). Therefore, it is
possible that boys with FXS may look more like children
with TD than children with DLD in terms of their tense
marking accuracy. However, a more nuanced pattern of
tense marking may emerge when examining productivity
using language sampling, where boys with FXS look simi-
lar to children with DLD for some tense markers and more
like children with TD for others.

Differences in measurement may also explain the fact
that children with DLD did not differ from children with
TD across all tense markers, but just in terms of third-
person singular and auxiliary BE productions. Typically,

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studies using more traditional measures of tense marking
in obligatory contexts have found differences between
preschool-age children with DLD and same-age and/or
MLU-matched peers in their use of all tense and agree-
ment marker types (e.g., Haebig et al., 2016; Leonard et al.,
1992; Rice & Wexler, 1996). However, when examining
tense using TAP scoring, Gladfelter and Leonard (2013)
also found that 4- to 5-year-old children with DLD had a
lower overall TAP total score, but did not differ from age-
matched children with TD in their productivity levels for
copula BE and past tense –ed. Thus, the results of Gladfel-
ter and Leonard map onto the findings in our study. As
such, researchers and clinicians should be cognizant of the
fact that the type of measurement selected may influence
the profile of tense marking they obtain, underscoring the
limitations of relying on one measurement type. Neverthe-
less, we believe these results complement prior research
using other assessment techniques and help to provide a
more complete profile of tense marking in children with
FXS and how it compares to DLD.

Examining Differences Across Individual Tense
and Agreement Markers

The second aim of this study was to examine chil-
dren’s productivity patterns across the five tense and agree-
ment types. All children, regardless of diagnostic group,
generally used copula BE more productively than all other
tense markers, with the exception of third-person singular,
which they produced at a similar rate. This finding is not
surprising given that copula BE and third-person singular
are known to be the earliest acquired tense morphemes
(Brown, 1973) and others have found them to generally
be the most productive forms when using TAP scoring
(Gladfelter & Leonard, 2013; Hadley & Short, 2005;
Rispoli et al., 2012). Also similar to previous research
(Gladfelter & Leonard, 2013; Hadley & Short, 2005), chil-
dren with DLD and TD used third-person singular more
productively than past tense –ed, auxiliary DO, and auxil-
iary BE. In contrast, for boys with FXS, there was not a
significant difference in their productivity for third-person
singular, past tense –ed, auxiliary DO, or auxiliary BE.
Instead, they demonstrated a more even profile across
these four tense markers. There are a couple of possible
explanations for this distinctive profile in boys with FXS.
First, it may be that boys with FXS show phenotypic dif-
ferences in the developmental sequence of individual tense
markers compared to children with DLD or TD. Second,
while there was not a significant relationship between
TAP performance and chronological age, it may also be
that the boys with FXS had more experience using some
tense markers (e.g., auxiliary DO) as a result of being chro-
nologically older. Finally, it is possible that differences in
sampling context (play-based vs. semistructured conver-
sation) could have influenced tense marker production,
though sampling procedures were considered to be age
appropriate for the respective groups and both styles were
conversational in nature.

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Relations Between TAP Performance, Age, IQ,
and Other Expressive Language Measures

Consistent with previous research (e.g., Rice et al.,
2004; J. A. Roberts et al., 2004; Sterling et al., 2012), we
found that tense and agreement productivity was not tightly
linked with nonverbal cognition. Similarly, tense and agree-
ment productivity was generally not related to chronologi-
cal age, though there was one exception (i.e., age was related
to copula BE production in DLD). The limited number of
associations with chronological age was somewhat unexpected
given that some research has shown that both children with
TD and DLD show growth in tense and agreement produc-
tivity during early childhood (Leonard et al., 2017; Rispoli
et al., 2012), though this has not been found in all studies
(Gladfelter & Leonard, 2013). Relatedly, others have dem-
onstrated that boys with FXS show improvement on stan-
dardized assessments of grammar over time, albeit at a
slower rate than boys with TD matched on nonverbal men-
tal age (Martin et al., 2013). It is possible that there was not
enough variability in chronological age among the children
in our study, particularly those with DLD and TD, to show
similar developmental differences in tense and agreement
productivity. Nevertheless, these findings further support our
decision to not include age and nonverbal ability as covariates.

We also examined the relationships between the
TAP total score and other measures of expressive grammar
and vocabulary. As expected, based on previous research
(Hadley & Short, 2005), children in all three groups dem-
onstrated a consistent profile of expressive grammar across
the measures taken from language samples—that is, those
who used tense and agreement markers more productively
had longer MLUs. Although significant for all groups, the
association between the TAP score and MLU was stronger
in children with TD and boys with FXS (r ≥ .70) compared
to children with DLD (r = .46). Thus, tense marking, while
related to MLU, may not be as tightly connected in chil-
dren with DLD. Similarly, lexical diversity measured via
NDW was related to the TAP total score in boys with
FXS and children with TD, but not in children with DLD.
Thus, for children with FXS and TD, those with better
expressive vocabulary abilities had better expressive gram-
mar abilities. In contrast, lexical diversity was not related
to tense productivity in children with DLD, which may
suggest that the tense marking difficulties present in DLD
are so significant that there is no relationship between NDW
and productivity. Although several studies have found a
correlation between grammar and vocabulary (Blom &
Boerma, 2019; Hadley & Short, 2005), there is some prior
work to suggest that finiteness marking and vocabulary
development follow different trajectories in children with
DLD and that performance on finiteness marking tasks is
not predicted by vocabulary ability (Rice et al., 2009).
Unlike MLU and NDW though, there was not a signifi-
cant link between the TAP total score and the TEGI. This
finding further underscores that these assessments are tap-
ping into different dimensions of tense marking (produc-
tivity vs. accuracy) and that both types of measurement

1181–1194 • April 2020

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should be used to gain a comprehensive profile of tense
marking abilities.

Limitations and Future Directions
Although findings from this study deepen our under-

standing of tense marking in DLD and FXS, several limi-
tations must be discussed. First, the three groups differed
significantly in terms of sex. Given that FXS is an X-linked
disorder and girls with FXS can be, but are not always,
less affected (Hagerman & Hagerman, 2002), only boys
with FXS were included in this study. Although boys tend
to have slightly higher rates of DLD (Whitehouse, 2010),
sex differences are not as pronounced in DLD, and so studies
commonly include both boys and girls (e.g., Gladfelter
& Leonard, 2013; Guo & Eisenberg, 2014; Leonard et al.,
2017). Nevertheless, future research comparing children
with DLD and FXS could benefit from more closely match-
ing on sex. Second, though the Leiter International Perfor-
mance Scale–Revised and the RIAS are both correlated
with other overlapping measures of IQ (e.g., both corre-
lated with the Wechsler Intelligence Scale for Children;
Reynolds & Kamphaus, 2003; Roid & Miller, 1997) and
others have used different IQ measures to assess cognition
within their samples of children with and without develop-
mental disorders (Fortunato-Tavares et al., 2015; Haebig
et al., 2016; Pickles et al., 2009), it is unclear whether there
is concurrent validity between these two measures of non-
verbal IQ. Third, we chose to measure TAP performance
based on the first 100 utterances. It is possible that longer
samples may have provided an opportunity for greater
productivity and allowed for more pronounced distinctions
between the groups to emerge. Moreover, though language
sampling methods were selected for several reasons (e.g.,
age appropriateness), language samples differed between
the boys with FXS and children with DLD and TD, which
could have influenced language performance. Finally, in
order to more fully understand the grammar profiles of
DLD and FXS, it will be important for research to compare
these clinical groups utilizing other assessment techniques
(e.g., frequency of tense errors in natural language sam-
ples) and to examine whether different trajectories of tense
marking emerge over time.

Conclusions and Clinical Implications
Although additional work is needed to understand

the unique language phenotypes of FXS and DLD, the
findings from this study further elucidate the areas of com-
monality as well as distinction in tense and agreement pro-
ductivity among boys with FXS and DLD. Specifically, we
found that children with FXS and DLD used some tense
markers (e.g., third-person singular) less productively than
MLU-matched children with TD and that boys with FXS
were generally similar in tense and agreement productivity
compared to children with DLD (with the exception of
auxiliary DO). However, boys with FXS demonstrated a
relatively even profile of productivity across the tense and

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agreement types, whereas children with DLD and TD
showed a pattern of most-to-least productive tense mor-
phemes that generally looked like that reported by others
(Gladfelter & Leonard, 2013; Rispoli et al., 2012). In
terms of clinical implications, our findings highlight the
importance of using multiple techniques to determine the
degree to which tense marking profiles differ in boys with
FXS compared to children with DLD and children with
TD. Such procedures will also be essential for determining
the degree to which language intervention focusing on
finiteness may need to be uniquely tailored to each clinical
group.

Acknowledgments
We would like to acknowledge the funding sources that

supported this project: R03 DC011616 (awarded to Sterling), U54
HD090256 (awarded to Chang), T32 HD07489 (awarded to
Hartley), F31 DC009135 (awarded to Hoover), and T32 DC000052
(awarded to Rice), as well as start-up funds from the University of
Wisconsin–Madison (awarded to Sterling). We would like to
thank the children and families who participated in this research,
as well as the lab members who contributed to this work, with
particular thanks to past and present members of the Research
in Neurodevelopmental Disabilities Lab at the University of
Wisconsin–Madison and the Sounds 2 Syntax lab at the University
of Massachusetts Amherst.

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Examples

Copula BE
All instances of copula BE in the sample:
C: Is this a frog?
C: Those are silly ducks.
C: The cows are not ready.
C: The cows are over there.
C: Is that some hay?
C: All of the ducks are in the pond.
C: The dog is brown.

Total:
Third-person singular
All instances of third-person singular in the sample:
C: He fits.
C: He wants to ride.
C: She wants to go.
C: He just stands up on it.
C: Abby calls him meow meow.
C: It moves this.

Total:
Past tense –ed
All instances of past tense –ed in the sample:
C: I dropped it.
C: He jumped up.
C: I dropped her.
C: I closed it.

Total:
Auxiliary BE
All instances of auxiliary BE in the sample:
C: I was riding in the back.
C: Are you gonna put your feet up?
C: She was spitting on me all day.

Total:
Auxiliary DO
All instances of auxiliary DO in the sample:
C: Do they go in here?
C: Do you hear that?

Total:

Note. TAP = tense and agreement productivity.
aUtterances with copula BE, auxiliary BE, and auxiliary DO wer
different sentence subjects. bUtterances with third-person sing

1194 Journal of Speech, Language, and Hearing Research • Vol. 63 •

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Whitehouse, A. J. O. (2010). Is there a sex ratio difference in the
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analysis. Journal of Speech, Language, and Hearing Research,
53(4), 1015–1025. https://doi.org/10.1044/1092-4388(2009/09-0078)

Appendix

Examples of TAP Scoring for Each Tense Type

Scoring (out of 5)a

1
1
1

0 (same sentence subject)
1
1

0 (reached max score of 5)
5

Scoring (out of 5)b

1
1

0 (same verb)
1
1
1
5

Scoring (out of 5)b

1
1

0 (same verb)
1
3

Scoring (out of 5)a

1
1
1
3

Scoring (out of 5)a

1
1
2

e included in the TAP score if they occurred with
ular and regular past tense –ed were included in the

TAP score if they occurred with different verbs.

1181–1194 • April 2020

ms of Use: https://pubs.asha.org/pubs/rights_and_permissions

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

Br J Learn Disabil. 2020;48:69–77. wileyonlinelibrary.com/journal/bld  |  69© 2020 John Wiley & Sons Ltd

Received: 9 August 2019  |  Revised: 4 December 2019  |  Accepted: 11 January 2020

DOI: 10.1111/bld.12318

O R I G I N A L A R T I C L E

Palliative care needs of direct care workers caring for people
with intellectual and developmental disabilities

Jennifer A. Gray  | Jinsook Kim

School of Health Studies, Northern Illinois
University, DeKalb, IL, USA

Correspondence
Jennifer A. Gray, School of Health Studies,
Northern Illinois University, 250 Wirtz Hall,
DeKalb IL 60115, USA.
Email: [email protected]

Funding information
Northern Illinois University CHHS
Community Endowment Fund grant;
Northern Illinois University

Accessible summary
• Palliative care is a holistic model of care that lessens suffering and improves qual-

ity of life for individuals who are very sick.
• As people with intellectual and developmental disabilities (PWIDD) get very sick,

direct care workers (DCWs) are more likely to provide palliative care.
• Researchers need to know more about what palliative care training DCWs need.
• One hundred and forty-nine (149) DCWs filled out surveys about their palliative

care training needs.
• The research showed that DCWs need more training in certain areas, such as

cultural competence, effective communication, post-death logistics and legal
matters.

Abstract
Background: Direct care workers (DCWs) caring for people with intellectual and
developmental disabilities (PWIDD) provide palliative care, but research indicates
DCWs are ill-equipped to do so. This study aimed to assess DCWs’ palliative care
experience and training and their perceived training needs.
Materials and Methods: Staff trained as DCWs (n = 149) in organisations that serve
PWIDD were surveyed in suburban and rural areas of a U.S. Midwestern state.
Descriptive statistics were run, including t tests, analysis of variance, Scheffe’s tests
for pairwise comparison, Pearson’s correlation, Fisher’s exact tests and chi-square
tests.
Results: Participants reported limited experience in legal matters, yet had substantial
experience in assisting PWIDD with pain, distress and bereavement. Training was in-
adequate but desired for cultural competence, effective communication, post-death
logistics and legal matters. Rural DCWs reported less palliative care experience and
training than suburban counterparts.
Conclusions: The results demonstrate the need for specific types of palliative care
training among DCWs caring for PWIDD and that such training should be prioritised in
rural agencies. Future research can explore ways to maximise training effectiveness.

K E Y W O R D S

direct care workers, intellectual and developmental disabilities, needs assessment, palliative
care, training

70  |     GRAY And KIM

1  | INTRODUC TION

Direct care workers (DCWs) play a critical role in the lives of people with
intellectual and developmental disabilities (PWIDD) throughout their
lives to support good health, community integration and independence
(Paraprofessional Healthcare Institute, 2013).1 Palliative care is a holis-
tic model of care that focuses on the alleviation of suffering and on im-
proving quality of life by meeting the physical, social, psychological,
cultural and spiritual needs of people with chronic and life-limiting ill-
nesses and their families (World Health Organization, 2015). With in-
creasing longevity (Coppus, 2013; World Health Organization & The
World Bank, 2011), more PWIDD are experiencing chronic health con-
ditions, increasing the likelihood of palliative care services needed
(McCarron, McCallion, Fahey-McCarthy, & Connaire, 2010; Ryan,
Guerin, Dodd, & McEvoy, 2011a). Direct care workers often do not have
the necessary skills or experience to provide palliative care for PWIDD
(McCarron et al., 2010; Ng & Li, 2003; Ryan et al., 2011a; Stein, 2008).

Staff in the intellectual and developmental disability (IDD) field
have shown a lack of knowledge and efficacy in providing palliative
care (Cartlidge & Read, 2010; Fahey-McCarthy, McCarron, Connaire, &
McCallion, 2009; Ng & Li, 2003; Ryan, McEvoy, Guerin, & Dodd, 2010).
The literature demonstrates that the care provided to PWIDD can de-
teriorate if IDD staff receive inadequate palliative care training (Gray
& Kim, 2017; Kim & Gray, 2018; Reynolds, Guerin, McEvoy, & Dodd,
2008; Ryan et al., 2011a; Watters, McKenzie, & Wright, 2012).

Cognitive and motor-related disabilities can make it more diffi-
cult for PWIDD to communicate their needs for palliative care as
well as how they feel (Stein, 2008). Subsequently, staff visual assess-
ment of PWIDD pain levels and health status is critical (Friedman,
Choueri, & Gilmore, 2008).

Though DCWs generally do not participate in the formal palli-
ative care decision-making process to produce the final advance
directives document, it is important that they are familiar with ad-
vance directive concepts (Lohiya, Tan-Figueroa, & Crinella, 2003).
Their conversations with family members may be critical as the ad-
vance directives are constructed (Guinn & Winston, 2018).

Whilst family members often have keen insights regarding the palli-
ative care of family members with IDD (Stein, 2008), they also may seek
to protect their loved ones from knowledge of their illness (Ryan, Guerin,
Dodd, & McEvoy, 2011b). IDD staff can benefit from more training to
speak with family members and PWIDD more specifically about issues
specific to death and dying (Codling, Knowles, & Vevers, 2014; Ryan et
al., 2011b; Stein, 2008; Tuffrey-Wijne, Rose, Grant, & Wijne, 2017).

Moreover, though research has shown that IDD staff understand
challenges that PWIDD may encounter regarding bereavement, addi-
tional training can increase staff’s efficacy (Reynolds et al., 2008) and
knowledge (Watters et al., 2012) in providing bereavement supports.
For example, staff may overestimate PWIDDs’ conceptual understand-
ing of death and not fully appreciate PWIDDs’ behavioural difficulties
due to grief (Watters et al., 2012; McEvoy, MacHale, & Tierney, 2012).

To date, there is limited needs assessment data for IDD staff
providing palliative care. Hahn and Cadogan (2011) conducted a
comprehensive needs-based palliative care train-the-trainer cur-
riculum for IDD staff based on a comprehensive needs assessment
and process to identify and validate the curriculum topics (Hahn &
Cadogan 2011). Ng and Li (2003) also conducted a needs assessment
of nursing IDD staff regarding death and dying, using an open-ended
response format. Participants voiced needs to improve their skills
in caring for PWIDD who are dying and to develop their verbal and
nonverbal communication skills (Ng & Li 2003) .

Other IDD-related studies have focused on end-of-life staff train-
ings. Such studies have identified IDD staff challenges such as when
and how end-of-life care should be provided (Tuffrey-Wijne, Hogg,
& Curfs, 2007), assessing and managing pain (Fahey-McCarthy et al.,
2009; Friedman, Choueiri, & Gilmore, 2008), providing proper nutrition
and hydration (Fahey-McCarthy et al., 2009; Friedman et al., 2008), de-
veloping cultural competency (Fahey-McCarthy et al., 2009) and com-
municating with PWIDD and family members about end-of-life-related
matters (Codling et al., 2014; Ng & Li, 2003; Tuffrey-Wijne et al., 2017).
Some IDD studies have focused specifically on grief and bereavement,
responding to IDD staff needs for managing their grief process, and
being a support to PWIDD and family members experiencing grief and
bereavement (Reynolds et al., 2008; Watters et al., 2012).

Although previous research has identified certain aspects of DCWs’
palliative care experience, existing palliative care training and training
needs, there have been no data that have assessed the training needs
for a wide range of palliative care topics in quantitative terms, specif-
ically for DCWs. Studies tend to focus on a single or a few aspects of
palliative care only (Ng & Li, 2003; Ryan et al., 2010) and collect infor-
mation from non-DCWs or a small sample of DCWs (Cartlidge & Read,
2010; Hahn & Cadogan, 2011; McEvoy et al., 2012; Ryan et al., 2010;
Stein, 2008; Wark, Hussain, & Edwards, 2014). Many studies are pri-
marily qualitative in nature (Cartlidge & Read, 2010; Fahey-McCarthy
et al., 2009; McCarron et al., 2010; Ryan et al., 2011a, 2011b), and
none report data on DCWs in the United States.

2  | AIMS

The purposes of the study were twofold. Primarily, we sought to as-
sess a wide range of palliative care continuing education needs of
DCWs from a U.S. Midwestern state using quantitative measures.
Secondarily, we identified the DCWs’ preferences regarding pal-
liative care training in order to develop a training programme that
meets the needs and preferences of DCWs.

3  | MATERIAL S AND METHODS

Seven nonprofit community-based organisations serving people
with IDD were selected through convenience sampling from rural
and suburban areas of a U.S. Midwestern state. Direct care work-
ers currently working with the title of “direct support professional

1 DCWs is a general term that encompasses individuals titled as direct support
professionals (DSPs) or front-line supervisors in this field.

     |  71GRAY And KIM

(DSP)” or who served in a supervisory or managerial position, with
training as a “direct support professional” (n = 149), were recruited
with flyers and letters that were distributed throughout the or-
ganisations. The study was approved by the University Institutional
Review Board and the participating organisations’ review processes,
and informed consent was obtained before participation.

3.1 | Instrument

Participants completed a self-administered survey in hard copy
(79%, n = 118) or online (21%, n = 31) format. Those who wanted
a paper-based survey completed the survey when the research
team visited their organisation. Participants who preferred an
online survey provided their email address and received a link
to the online survey via email. Two organisations chose to par-
ticipate in online format only. The survey consisted of three sec-
tions: (a) demographic and work-related information; (b) palliative
care-related information; and (c) preferred training formats. Due
to the lack of quantitative survey instruments specifically for
the assessment of palliative care training needs of IDD staff, the
authors developed the survey by selecting topics or items from
the existing palliative care and end-of-life care literature in IDD
and non-IDD fields (Adriaansen, Van Achterberg, & Borm, 2005;
Bekkema, de Veer, Hertogh, & Francke, 2015; Cartlidge & Read,
2010; Fahey-McCarthy et al., 2009; Gerhardt et al., 2009; Hahn &
Cadogan, 2011; Hobday, Savik, Smith, & Gaugler, 2010; Kirkendall
& Waldrop, 2013; McCarron et al., 2010; McEvoy et al., 2012;
Ng & Li, 2003; Nochomovitz et al., 2010; Phillips, Salamonson, &
Davidson, 2011; Ryan et al., 2010; Ryan et al., 2011a; Ryan et al.,
2011b; Stein, 2008; Todd, 2013; Tuffrey-Wijne et al., 2007; Wark
et al., 2014; Wittenberg-Lyles, Goldsmith, Ferrell, & Burchett,
2014) and the authors’ own research using focus group data from
IDD staff (Gray & Kim, 2017; Kim & Gray, 2018).

3.2 | Demographic and work-related information

The survey included items about demographic and work-related
information, including age, gender, residential location, race/eth-
nicity, education level, job title and time in the IDD field. These
items were included to identify the demographic composition of
the participants and to examine whether palliative care experi-
ence, previous training and perceived training needs differ by
these characteristics.

3.3 | Palliative care-related information

3.3.1 | Previous palliative care experience

Experiences with palliative care were captured in 12 items with yes
or no responses to a question “Have you EVER been in a situation

that involved or made you think about the following issues?” We
named the count of affirmative responses to the 12 questions (rang-
ing from 0 to 12) “palliative care experience score.”

3.3.2 | Previous training in palliative care

Past training in palliative care was reflected in 31 items with yes or
no responses to a question “Have you EVER taken an educational
course or training that teaches you the following subject matter?”
The count of affirmative responses to the 31 questions (ranging from
0 to 31) was named “palliative care training score.”

3.3.3 | Perceived needs for palliative care training

Perceived needs for palliative care training was captured with 31
items using a statement “I feel the need for training on the follow-
ing,” with 5-point Likert-style responses, that ranged from strongly
disagree (coded 1) to strongly agree (coded 5). Summing the points
(ranging from 1 to 5) of 31 questions, named “palliative care train-
ing needs score,” yielded scores ranging from 31 to 155. The three
scores that we named as “palliative care experience score,” “pallia-
tive care training score” and “palliative care training needs score”
were developed specifically for this study.

3.4 | Preferred training formats

The survey queried participants about their preference in terms of
training format, length and delivery method. Internet access was
also asked to explore the feasibility of online training.

3.5 | Analysis

Sample characteristics and the distribution of individual items were
examined using percentages and means. Differences in sample char-
acteristics and Internet access by location (rural vs. suburban) were
examined using chi-square tests and t tests. Additionally, differences
in main outcome scores were examined by job title, location and race
using t tests and analysis of variance (ANOVA). Since the three main
outcome scores were not normally distributed, both parametric and
nonparametric statistical methods were used and results were com-
pared. The literature recommends parametric statistical methods
such as a t test and ANOVA over nonparametric methods when sam-
ple sizes are moderate or large (n > 30) and skewness or kurtosis is
low (Rasch & Guiard, 2004). When an ANOVA result was significant,
the Scheffé pairwise comparison method (Savin, 1980) was used to
identify specific pairs of categories that were statistically different
from one another. The association between continuous variables,
such as years in the IDD field and three main outcome scores, was
examined using Pearson’s correlation.

72  |     GRAY And KIM

4  | RESULTS

4.1 | Participant characteristics

Table 1 provides socio-demographic information of the sample.
Participants’ ages were from 22 to 68, with a mean age of 41.7. Eighty-
six per cent (n = 128) of participants were female. The majority were
White (60.4%), followed by Black/African American (34.2%). Whilst
one-fifth had completed only high school (21.5%), about one-fourth
had earned a bachelor’s degree (26.2%). Just over half identified as a di-
rect support professional (57.1%), 24.2% as a front-line supervisor and
18.8% as managers. Participants reported a mean number of 10.1 years
working in the IDD field. There was no difference in individual charac-
teristics or main outcomes by survey mode (i.e. paper-based vs. online).

4.2 | Survey results

Table 2 provides information on participants’ previous palliative care
experience. The distribution of experience with palliative care varied
from 40% to 80% depending on the topic or area. Less than half of
the participants reported having palliative care experience related to
legal matters (40.3%). More than 80% of participants indicated that
they were in a situation involving coping with their own grief (86.6%)
or supporting others in grief (85.2%).

Table 3 includes information on participants’ previous training
and perceived needs for training. Previous palliative care training
also varied widely by training topic or area. The least trained area
was logistics after a client’s death (30.2%). Other less-trained areas
included legal matters including advance directives (35.6%) and the
unique hospice care needs of PWIDD (38.3%). Meanwhile, more
than two thirds of participants had training on dementia/Alzheimer’s
disease of PWIDD (69.8%), patterns/stages of grief (76.5%) and cop-
ing with grief (73.2%).

Across all training areas, participants’ perceived needs for train-
ing was quite high (70%–80%), regardless of their past training expe-
rience. For example, even though 76.5% of participants had previous
training in patterns/stages of grief, 73.7% of participants still ex-
pressed a need for training in this area.

Table 4 shows the bivariate results regarding participants’ pallia-
tive care experience, palliative care training and needs for palliative
care training with respect to job title, location and race. Internal con-
sistency of the items in three composite scores was acceptable with
the Cronbach’s alpha 0.89 from 12 items, 0.96 from 31 items and
0.98 from 31 items, respectively.

Parametric tests are robust and preferred for non-normal-de-
pendent variables if sample sizes are large enough and skewness
or kurtosis is low (Rasch & Guiard, 2004). Since the three outcome
variables met these criteria, results from t tests and ANOVA are
presented. Nonparametric tests (Wilcoxon rank-sum and Kruskal–
Wallis tests) produced the same results as parametric tests.
Experience with palliative care varied by job title (p < .05 in ANOVA)
with DSPs reporting less palliative care experience than managers.
Participants in rural areas also reported less palliative care experi-
ence (p < .05 in t tests) and less palliative care training (p < .0005 in
t tests) than those in suburban areas. There was a difference in past
palliative care training by race (p < .0005 in ANOVA). Black/African
American participants received more training than White partici-
pants (p < .0005 in Scheffé pairwise comparison; results not shown
in tables). Although suburban agencies had higher percentages of
Blacks/African Americans than rural agencies, regression analysis in-
dicated that Black/African American participants had more training
than White counterparts even when the location and tenure in the
field were controlled for.

Participants’ perception of palliative care training needs dif-
fered by job title (p < .05 in ANOVA). Managers expressed the need
for training more than DSPs (p < .05 in Scheffé pairwise compar-
ison). There was no significant difference in perception of train-
ing needs between managers and front-line supervisors (p > .05)

TA B L E 1   Participant characteristics (n = 149)

Number Percentage

Age 41.7 (mean) 22–68 (range)

Gender

Female 128 85.9

Male 21 14.1

Race

White 90 60.4

Black/African American 51 34.2

Other 8 5.4

Education

High school 32 21.5

Some college 54 36.2

Associate’s degree 14 9.4

College 39 26.2

Graduate/professional 10 6.7

Job title

Direct support
professional

85 57.1

Front-line supervisor 36 24.2

Manager 28 18.8

Geographical location

Suburban 61 40.9

Rural 88 59.1

Years working in IDD
field

10.1 (mean) 1–45 (range)

Organisation

A 52 34.9

B 16 10.7

C 28 18.8

D 24 16.1

E 8 5.4

F 8 5.4

G 13 8.7

Note: IDD, intellectual and developmental disability.

     |  73GRAY And KIM

or between DSPs and front-line supervisors (p > .05) (results not
shown in tables).

In correlation analysis, the degree of palliative care experience
(measured by the palliative care experience score) was positively
correlated with that of past training (measured by the palliative care
training score) as indicated by Pearson’s correlation coefficient r
(.42, p < .05) (results not shown in tables). Perceived palliative care
training needs (measured by palliative care training needs score) was
not correlated with either palliative care experience or past palliative
care training.

In terms of training delivery methods, participants preferred
in-person (67.6%), followed by hybrid (23.7%) and online (8.8%).
Participants also preferred that case studies (57.7%), discussion
(71.8%) and video (63.8%) be part of the training format, indicating
the need for diverse and interactive training formats. The majority
of participants (96.6%) reported having Internet access with virtually
no difference by location.

5  | DISCUSSION

To our knowledge, this is the first study that quantitatively assessed
the needs of palliative care training of DCWs caring for PWIDD
using an instrument covering a wide range of palliative care topics
and a sizable number of DCWs in the United States. Participants’
experience and training in palliative care varied widely across topic
areas. Participants’ perceived needs for training was, however, quite
high across all training topics/areas regardless of their past training
experience. Those who have limited training are likely to recognise
the need for more training and guidance in order to perform their
job at a certain level of competency, and those with higher levels of
training are likely to appreciate the value of training and the need

for more training, based on problems they observe from their work
in the field.

Participants reported the most limited palliative care experi-
ence in legal matters (e.g. advance care planning), whilst indicating
more exposure to other issues such as recognising and reducing
pain, and grief management. Moreover, though participants ex-
pressed their desires for further palliative care training in virtually
all areas, less than half of participants reported having had training
in care planning and provider coordination, end-of-life care issues
and cultural competence for effective communication with family
members.

With respect to care planning and provider coordination, <40%
of participants indicated previous training on advance directives
and unique hospice care needs of PWIDD. Though DCWs are not
actively involved in the advance directive process, they need to be
aware of what advance directives are and be able to alert supervi-
sors when PWIDD or family members want to talk about such issues.
The research literature has shown that having conversations about
such matters lays the bedrock for the development of good advance
directives (Friedman et al., 2008; Guinn & Winston, 2018; Voss et al.,
2017). Participants also acknowledged limited understanding of how
hospice care needs are different for PWIDD. DCWs’ clearer under-
standing of PWIDD’s unique palliative care needs can help hospice
and IDD staff work together more seamlessly, if needed (Bekkema et
al., 2015; Friedman et al., 2008; Voss et al., 2017).

Regarding end-of-life care, less than half of participants had
training on practical aspects of end-of-life care such as how to talk
about death with PWIDD, assessing and managing pain and distress
of PWIDD, and what to do after a client dies. The research litera-
ture has demonstrated that PWIDD have more difficulty express-
ing their needs and understanding the nature of their illness due to
their disabilities (Bekkema, Veer, Hertogh, & Francke, 2016; Ryan

Have you EVER been in a situation that involved or
made you think about the following issues? Frequency (Yes) Percentage

Unique needs of PWIDD requiring palliative care 119 79.9

Strategies and activities that promote well-being of
PWIDD requiring palliative care

124 83.2

Legal matters 60 40.3

Options for hospice care for PWIDD 80 53.7

Communication with hospice care providers or other
teams involved in palliative care

86 57.7

Talking about death with family members 105 70.5

Recognising and reducing pain and distress 117 78.5

Talking about death with PWIDD 103 69.1

How to behave in the presence of a dying person 106 71.1

What to do after death of PWIDD 99 66.4

How to cope with my own grief 129 86.6

How to support other clients, family members and co-
workers through the process of grief

127 85.2

Note: PWIDD, people with intellectual and developmental disabilities.

TA B L E 2   Previous palliative care
experience (n = 149)

74  |     GRAY And KIM

TA B L E 3   Previous training and perceived needs for training

Previous Palliative Care Training
(n = 149)

Perceived Needs for Palliative
Care Training (n = 148)

Frequency (Yes) Percentage Frequency (Yes) Percentage

Palliative care general

Problems of growing old for people with intellectual/developmental
disability (PWIDD)

95 63.8 113 76.4

Dementia and Alzheimer’s disease among PWIDD 104 69.8 113 76.4

Risks of Alzheimer’s disease for PWIDD 93 62.4 110 74.3

Unique physical needs of PWIDD requiring palliative care 89 59.7 109 73.7

Unique spiritual, social and emotional needs of PWIDD requiring
palliative care

81 54.4 121 81.8

Strategies and activities that promote the well-being of PWIDD
requiring palliative care

97 65.1 116 78.4

Understanding and supporting PWIDD requiring palliative care who
are from diverse cultural backgrounds

70 47.0 117 79.1

Care planning and provider coordination

Basic principles of palliative care 99 66.4 113 76.4

Values and choices in palliative care 88 59.1 117 79.1

Legal matters including advance directive 53 35.6 107 72.8

Palliative care planning 71 48.3 114 77.0

Organisational policies on palliative care 61 40.9 117 79.1

What should be considered in end-of-life decision-making 66 44.3 118 79.7

Options for hospice care for PWIDD 60 40.3 115 77.7

Unique hospice care needs for PWIDD 57 38.3 115 77.7

Communication with hospice care providers and other teams
involved in palliative care

65 43.6 114 77.0

Family communication

How to talk about death with family members 83 55.7 114 77.0

Cultural competence to effectively communicate with family
members from diverse backgrounds

61 40.9 120 81.1

End-of-Life Care

Assessment and management of pain and distress 74 49.7 114 77.0

The physical process of dying 78 52.4 112 75.7

How to talk about death with PWIDD 74 49.7 120 81.1

Appropriate behaviour in the presence of a dying person 82 55.0 112 75.7

What is a good death 53 35.6 115 77.7

Spiritual and cultural context in end-of-life issues 57 38.3 116 78.4

What to do after death: business side, logistics 45 30.2 119 80.4

Bereavement

Patterns and stages of grief 114 76.5 109 73.7

Spiritual and cultural context in grief 70 47.0 118 79.7

Rituals and closure 64 43.0 115 77.7

How to cope with grief 109 73.2 113 76.4

How to support other clients, family members and co-workers
through the process of grief

98 65.8 115 78.2

How to access internal or external organisational resources to
support your grief and coping process

79 53.0 117 79.1

Note: PWIDD, people with intellectual and developmental disabilities; PC, palliative care; EOL, end of life.

     |  75GRAY And KIM

et al., 2011b). Staff may be uncertain as to what extent PWIDD were
aware of their life-limiting conditions (Ryan et al., 2011b) and how to
explain a client about his or her health condition (Tuffrey-Wijne et
al., 2017), which can impede the provision of end-of-life care. This
can make it difficult for staff to assist with pain management (Stein,
2008). Although DCWs have no clinical authority to help PWIDD
manage pain by prescribing medications, they can help PWIDD in
other ways, such as with stress management tools (deep breathing
exercises, soothing music, etc.) and referring to clinicians who can
prescribe pain medications.

With respect to family communication, only 41% of participants
reported having training on cultural competence to effectively com-
municate with family members from diverse backgrounds. Such
backgrounds often are related to diverse expectations and norms re-
garding religious and spiritual beliefs at end of life (Hahn & Cadogan,
2011).

Family members often play a very important role in the lives of
PWIDD who have severe illness. They may have difficulty accepting
the trajectory of their loved one’s decline and what this may entail
and often need emotional support. In some cases, a family member
may prevent a PWIDD from learning about his or her illness (Ryan
et al., 2011b). Additionally, family members often have valuable in-
sights into the needs and care of the PWIDD, and need to convey
such information to staff (Stein, 2008). Though DCWs do not have
the authority to make decisions about palliative care plans, they
play a critical customer service role for IDD organisations. Being
that DCWs often are more readily accessible than managers, family
members’ questions and concerns regarding palliative care are often
initially raised with DCWs. DCWs need training so that they can
speak with family members in an informed way, until management
can provide a more complete response.

Though participants indicated having previous training in be-
reavement, they maintained significant needs for training in these
areas. Other research has found that though staff understand basic
bereavement-related needs of PWIDD, they do benefit from addi-
tional training, which can increase staff’s level of efficacy (Reynolds
et al., 2008) and knowledge (Watters et al., 2012) in providing be-
reavement supports. For example, staff may overestimate the con-
ceptual understanding that PWIDD have of death and not fully
appreciate the behavioural difficulties that PWIDD can experience
as a result of grief (Watters et al., 2012; McEvoy et al., 2012).

Participants in suburban locations demonstrated more palliative
care experience and training, which highlights the need for partici-
pants in rural areas to have additional training supports. Considering
the heaviness of the training content areas, participants indicated
that they would prefer the training to be delivered in in-person or
hybrid (online and in-person combined) formats. Although online
training was not the preferred delivery format, the high percentage
of rural participants having Internet access in this study indicates the
feasibility of online training for rural DCWs when in-person training
is not available.

6  | IMPLIC ATIONS FOR PR AC TICE

This study provides useful information in order to prepare DCWs
adequately in providing palliative care. Ideally, training can prioritise
the topic areas most lacking in DCWs’ practical and training experi-
ence, such as legal issues and logistics after death and address con-
tinued concerns such as bereavement-related topics. DCWs’ interest
in training formats incorporating case studies, discussion and video
suggests the need for creative and engaging training models. This is

TA B L E 4   Palliative care experience, training, and training need scores: mean and standard deviation

n

Palliative Care
Experience
Score (n = 149)
(0–12) p-value n

Palliative Care
Training Score
(n = 149)
(0–31) p-value n

Palliative Care
Training Need
Score (n = 148)
(31–155) p-value

Job title

DSP 85 7.7 (3.8) 85 16.4 (10.6) 85 117.1 (27.0)

Front-line supervisor 36 9.3 (3.1) 36 17.4 (9.4) 35 120 (25.4)

Manager 28 9.5 (2.7) <.05a 28 13.2 (8.7) 28 133.1 (23.8) <.05a

Location

Suburban 61 9.3 (3.1) 61 19.7 (9.4) 60 119.9 (31.2)

Rural 88 7.8 (3.7) <.05b 88 13.5 (9.7) <.0005b 88 121.4 (23.0)

Race

White 90 8.2 (3.7) 90 13.7 (9.7) 90 120.0 (25.1)

Black/African
American

51 8.7 (3.4) 51 20.5 (9.2) 51 121.5 (30.1)

Other 8 9.1 (3.3) 8 14.3 (9.8) <.0005a 7 125.9 (18.5)

Note: DSP, direct support professional.
aAnalysis of variance comparing score means between categories of an independent variable.
bA t test comparing score means between categories of an independent variable.

76  |     GRAY And KIM

in alignment with other studies showing DCWs’ preference for in-
teractive continuing education delivery with more frequent, shorter
sessions (Menne, Ejaz, Noelker, & Jones, 2007).

7  | LIMITATIONS AND FUTURE
DIREC TIONS

Generalisability of the findings of this study is limited because the
sample came from nonprofit organisations in a U.S. Midwest area,
and the study used convenience sampling. DCWs’ experiences
with palliative care and training and perceived training needs may
vary across different types of organisations and areas in the United
States. Inclusion of IDD staff who volunteered to participate in the
survey may have affected the characteristics of the sample. The par-
ticipants are more likely to be interested in the study topic and will-
ing to express their thoughts or opinions than nonparticipants.

Using our newly developed instrument is another limitation.
The three summary scores were created using questionnaire items
developed specifically for this study. Due to a lack of existing in-
struments that quantitatively measure the concepts that we intend
to measure for our target group (DCWs serving PWIDD), a new in-
strument was developed based on extensive literature reviews and
our own research (Gray & Kim, 2017; Kim & Gray, 2018). Therefore,
comparing our results with those from past studies or other groups
is not possible.

Future research can explore ways to maximise training ef-
fectiveness and work-based applications. Our exploration of the
palliative care training needs of rural and suburban DCWs indi-
cates a considerable gap and relative needs among rural provid-
ers. Issues related to rural and suburban needs must be explored
further in future research investigation. Focusing palliative care
training among rural providers has promise to improve care in rural
areas. In terms of measurements, validation of the instrument with
more diverse and larger DCW samples and using thorough analysis
methods such as factor analysis and Rasch analysis are warranted
in order to develop a refined and standardised measure. Inclusion
of open-ended questions in surveys or conducting qualitative in-
terviews or focus groups may yield richer information on DCWs’
experiences. This can lay the groundwork for additional quantita-
tive analysis.

8  | CONCLUSION

This study has demonstrated key palliative care training needs
among DCWs in the IDD field. Participants reported limited ex-
perience with legal matters than other aspects of palliative care.
Participants expressed interest in more palliative care training over-
all and were less likely to be trained in areas such as logistics after
a client’s death, legal matters, cultural competence for effective
communication, and the spiritual and cultural context in end-of-life

care. This study highlights the palliative care training needs among a
lesser-studied staff group.

ACKNOWLEDG EMENTS
We are grateful for the support and assistance of our colleagues
from Northern Illinois University. This study was funded by a
Northern Illinois University College Tri-County Endowment grant.
This study was approved by the Institutional Review Board of
Northern Illinois University. The funding body has placed no re-
strictions on free access to or publication of the research data.
The content is solely the responsibility of the authors and does
not necessarily represent the official views of Northern Illinois
University. There are no author conflicts of interest related to this
manuscript.

DATA AVAIL ABILIT Y S TATEMENT
At this time, the research data are not shared. Please contact the
authors with any concerns or questions regarding this matter.

ORCID
Jennifer A. Gray https://orcid.org/0000-0001-9586-2444
Jinsook Kim https://orcid.org/0000-0001-8616-1988

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Organizational Commitment of N

urse Faculty Teaching in
Accelerated Baccalaureate Nursing Programs
Laureen M. Donovan and Camille L. Payne

ABSTRACT

AIM The aim of the study was to examine organizational commitment by exploring experiences of faculty in
Accelerated Bachelor of Science in Nursing (ABSN) programs.
BACKGROUND ABSN faculty report that the curriculum is intense and fast-paced.
METHOD A cross-sectional survey design was used to examine faculty organizational commitment. A 53-item self-
reported survey with closed questions measured organizational commitment, global job satisfaction, and work
conditions. ABSN programs were recruited using cluster random sampling from a five-region list of programs; 62
programs were recruited with total faculty participation of 104.
RESULTS ABSN faculty were found to be affectively and normatively committed to their organizations. Significant
predictor variables of work environment conditions were stress and experiences of shortcomings, professional
development, managerial support, and global job satisfaction.
CONCLUSIONAsABSN programs continue to flourish, it is important to identify strategies for faculty success within the
fast-paced curricula.

KEY WORDS Accelerated Nursing Education – Faculty Organizational Commitment – Faculty Work Environment –
Organizational Commitment Models

A
p
V
S
a
F
T
C
d

N

The Accelerated Bachelor of Science in Nursing (ABSN) pro-
gram has spread across the United States to address the
increasing need for nurses. According to the US Bureau

of Labor statistics (2019a), the need for nurses will increase by
12 percent; the need for nursing instructors and postsecondary
teachers will increase by 20 percent (US Bureau of Labor
statistics, 2019b) over the next 10 years. Therefore, intentional re-
search that evaluates all aspects of the teaching and learning pro-
cess in nursing education should be undertaken to understand
the ABSN program and its stakeholders. Research on the ABSN
curricula has focused predominantly on student needs and program
challenges; nurse faculty teaching this program remain understudied
(Brandt et al., 2015; Christoffersen, 2017).

ABSN program curricula are like those of traditional undergradu-
ate nursing programs, except for differences in pace and intensity,
with curricula compressed into 12 to 18 months rather than the
24 months of traditional BSN programs. Faculty who teach and facil-
itate ABSN programs have anecdotally noted the pace, intensity, and
stress of their programs (Christoffersen, 2017). However, the literature
regarding faculty perceptions of ABSN programs is limited. This
study’s goal was to evaluate the faculty viewpoint through the lens

bout the Authors Laureen M. Donovan, PhD, RN, CCRN, is assistant
rofessor, School of Nursing, Shepherd University, Shepherdstown, West
irginia. Camille L. Payne, PhD, RN, is professor emeritus, WellStar
chool of Nursing, Kennesaw State University, Kennesaw, Georgia. The
uthors thank Editage (www.editage.com) for English language editing.
or more information, contact Dr. Donovan at [email protected].
he authors have declared no conflict of interest.
opyright © 2020 National League for Nursing
oi: 10.1097/01.NEP.0000000000000764

ursing Education Perspectives

Copyright © 2021 National League for Nursing. Una

of an organizational commitment model, provide an in-depth faculty
perspective, and highlight strategies for faculty success. The research
question was as follows: What is the impact of the working experi-
ence of nurse faculty members in an ABSN program on their organi-
zational commitment?

BACKGROUND
ABSN faculty are a subset of the faculty who teach in more traditional
BSN programs. Two recent studies that explored the teaching expe-
rience of ABSN program faculty suggest that faculty who teach in ac-
celerated programs must have a strong teaching practice (Brandt
et al., 2015). Implications for ABSN faculty include a greater need
for course preparedness, greater use of technology, and more time
required for student interactions (Brandt et al., 2015; Christoffersen,
2017; Downey & Asselin, 2015). An additional study used a herme-
neutic phenomenological approach with 14 faculty members to focus
on the nurse faculty experience in ABSN programs. This study found
that faculty had feelings of inadequacy regarding teaching, confi-
dence, and student needs (Cangelosi, 2013). Courses were de-
scribed as intense, and faculty members needed to be ready each
time they went into the classroom; they often felt overwhelmed by
their students and their high expectations.

Outcomes from recent empirical research suggest that the fac-
ulty experience of ABSN programs is complex and challenging
(Christoffersen, 2017; Downey & Asselin, 2015). Challenges for fac-
ulty who teach in ABSN programs could cause a change in their com-
mitment to the organization. Myer and Allen (1997) noted that strong
employee commitment is related to a positive relationship between
the employee and the organization. Further research into the organiza-
tional commitment of ABSN faculty through an evaluation of their work
conditions will provide an opportunity to address deliberate approaches
to mentoring faculty and highlight strategies for nursing leadership.

VOLUME 42 NUMBER 2 81

uthorized reproduction of this article is prohibited.

Donovan and Payne

THEORETICAL FRAMEWORK AND PURPOSE
This study’s underlying theoretical framework was the multidimen-
sional organizational commitment (MDOC) model, introduced by
Myer and Allen (1991, 1997). The MDOC model describes the psy-
chological state between the worker and the organization. The nurse
faculty organizational commitment has been studied in terms of job
satisfaction, work climate, organizational support, and turnover intent; it
has been reported that stronger organizational commitment is potentially
correlated with stronger teaching, scholarship, and service outcomes
(Abou Hashish, 2017; Timalsina et al., 2018; Wang & Liesveld, 2015).

The MDOC model includes distal and proximal antecedents that
start with the organization’s specific characteristics. Distal organiza-
tional characteristics include size, demographics, compensation,
training, and environmental states within an organization. Proximal
antecedents are grounded in the employee’s work experiences (rela-
tionships, job scope, support, participation, and justice), role states
(ambiguity, conflict, and overload), and psychological contracts (eco-
nomic or social; Myer & Allen, 1997). TheMDOCmodel suggests that
distal and proximal organizational antecedents can affect the level of
the employee’s affective, normative, and continuance organizational
commitment. Furthermore, the model suggests that outcomes of or-
ganizational commitment can affect employee retention, well-being,
and productive behavior (Myer & Allen, 1997).

The antecedents chosen from the model for this study were
ABSN faculty’s distal and proximal antecedents of work environment
conditions (WEC) and how they relate to dimensional level commit-
ment (affective, normative, or continuance) and the outcome of em-
ployee well-being. An assumption is made that specific antecedents
from the model and faculty’s degree of commitment to the organiza-
tion can affect the employee physically and emotionally.

Affective commitment is the emotional commitment that the indi-
vidual has toward the organization (Myer & Allen, 1991, 1997). A
strong emotional commitment is one in which the individual wants
to contribute to the organization in a significant way. Continuance
commitment, which describes the relationship between the individual
and the organization, is grounded in the understanding that to leave
would not be cost effective. Positive continuance commitment sug-
gests that the individual does not stay with an organization because
of an emotional attachment but rather because of a practical attach-
ment. Normative commitment views the commitment as a responsi-
bility and obligation to the organization. An employee with normative
commitment does what is appropriate for the organization but does
not have as much enthusiasm for the organization as an employee
with positive affective commitment.

The MDOC model suggests that faculty needs within an ABSN
program can have multiple influences. The outcome of well-being re-
lates to employee work experiences that are experienced through the
environment. Therefore, it is suggested that work experience affects
the type of commitment (affective, normative, or continuance) and
the employee’s overall well-being, defined as psychological health,
physical health, and career progress (Myer & Allen, 1997). The rela-
tionship between worker commitment and well-being has not been
fully developed or explored in terms of the association between fac-
ulty and ABSN programs.

The purpose of this study was to examine organizational com-
mitment by exploring faculty experiences of the ABSN program.
Organizational commitment has been noted to be important
for understanding the employee’s obligation toward an organization.
Strong employee commitment suggests that a positive relationship

82 March/April 2021

Copyright © 2021 National League for Nursing. Una

exists between the employee and the organization (Myer & Allen,
1997). Identification of the faculty attitudes toward accelerated
nursing programs can provide nurse education leaders with an
awareness of faculty challenges and strategies to improve the
work environment.

METHOD
A quantitative methodology with a cross-sectional survey design was
used to provide a comprehensive view of faculty organizational com-
mitment in relation toWEC and job satisfaction. Approval to complete
this study was obtained from the university institutional review board
and any additional relevant institutional review boards requested by
program participants.

The target population was nurse faculty who teach in ABSN pro-
grams. The population and sample were drawn from the ABSN pro-
gram database created by the American Association of Colleges of
Nursing (AACN, 2014). The database includes 255 ABSN programs
in the United States, organized by state. Each entry includes the pro-
gram name, programs offered, location of each program (city/state),
and a link to the official program website. Programs were divided into
five regions: Northeast, Southeast, Southwest, Midwest, and West.
The sample was chosen by cluster random sampling of accelerated
programs within each region. The population of accelerated fac-
ulty was identified as a subset of the population of nurse faculty;
an expected population of 425 nurse faculty who teach in acceler-
ated programs was anticipated as potential participants based on a
95 percent confidence interval plus or minus 4 and a population of
1,453 (based on a study by Gutierrez et al., 2012). The sample size
calculator used was the Survey System 10.5, Creative Research
Systems.

Inclusion criteria included participants with an ABSN faculty
workload. Recruitment involved sending an introductory cover letter
to deans and directors of applicable programs. Once approval was
received, an online survey was forwarded to potential participants.
A cover letter was sent that identified the risks and benefits of partic-
ipation; completion of the online survey indicated consent.

Instruments
Three self-reported survey instrumentswere used. The 18-itemMDOC
Questionnaire (Myer & Allen, 1997) measures the affective, normative,
and continuance commitment dimensions of organizational commit-
ment. The internal consistency reliability of each subscale has been
reported (affective commitment, −.77 to .88; normative commitment,
.65 to .86; continuance commitment, .69 to .84; Carver et al., 2011).
Reliability estimates (Cronbach’s alpha) for the internal consistency of
each subscale are outlined in Table 1. Items are rated on a 7-point
Likert-type scale (1 = strongly disagree, 7 = strongly agree); four items
are scored in reverse.

The 26-item WEC Questionnaire (Severinsson & Hummelvoll,
2001) includes five subscales: stress and experiences of shortcom-
ings, general satisfaction, managerial support, communication and
cooperation, and professional development. The instrument has
been found to be reliable with an internal consistency of .86 and an
overall alpha coefficient of .9 (Vanaki & Vagharseyyedin, 2009). The
operational definition of the tool is that work environment is affected
by conditions the worker experiences. TheWEC has been evaluated
for reliability using Cronbach’s alpha for internal consistency (Table 1).
Items are rated using a Likert-type scale (1 = not at all, 6 = very much
so); nine items are scored in reverse.

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Table 1: Reliability Estimates (Cronbach’s Alpha)
of the Three Survey Scales (N = 104)

α

Organizational Commitmenta

Affective .91

Continuance .79

Normative .81

Work Environment Conditionsb

Stress and experiences of shortcomings .89

General satisfaction .92

Communication and cooperation .71

Managerial support .89

Professional development .60

Global Job Satisfactionc .95

aOrganizational Commitment Tool with subscales.
bWork Environment Conditions Tool with subscales.
cGlobal Job Satisfaction Tool.

ASBN Faculty Commitment

The Global Job Satisfaction (GJS) Tool is a six-item instru-
ment that measures an employee’s feelings about the job without
referring to any specific aspect of the job (Pond &Geyer, 1991). GJS
is positively correlated with affective commitment to the occupa-
tion and organization and negatively correlated with continuance
commitment and turnover (Pond & Geyer, 1991). The alpha coef-
ficient of this tool is .9 (Pond & Geyer, 1991); reliability has been ex-
amined using Cronbach’s alpha with internal consistency shown in
Table 1. A Likert-type scale is used with scores ranging from 1 (def-
initely not take the job) to 5 (definitely take the job).

The reliability estimates of the three measurement tools in this
study are within the parameters stated in previous studies, except
for the affective commitment subscale, which was slightly higher than
previously published. The WEC Scale required minor revisions to
represent nursing faculty in the educational setting. Copies of the
scales and permission to use them were received from all authors
of these tools.

Data Analysis
SPSS Version 23 statistical software (IBM Corp., Armonk, NY) was
used to analyze, organize, manage, store, and process the data col-
lected. Data analysis included both descriptive and inferential statis-
tics. Descriptive statistics were used to describe the participants
and the program. Inferential statistics were used to evaluate the dif-
ferences between the dependent and independent variables. Specif-
ically, independent samples t-tests were used to determine themean
differences between faculty demographic variables. Analysis of vari-
ance was used to test for mean differences between two or more
groups and evaluated the relationships between different groups.
An F ratio that varies between and within groups indicates the

Nursing Education Perspectives

Copyright © 2021 National League for Nursing. Una

likelihood that the independent variable can cause group differences
(Polit & Beck, 2012).

Regression and stepwise regression were used to explain the
dependent variables from one or more independent variables. The
dependent variable of organizational commitment was used to
evaluate the independent variables of WEC and GJS. Pearson’s
correlation coefficient was used to examine the relationships be-
tween the independent variables of the accelerated nursing faculty’s
WEC and GJS and the dependent variables of affective, normative,
and continuance commitment. Accepted level of significance was
p ≤ .05 (two-tailed).

RESULTS
Sixty-two of 255 self-identified ABSN programs were randomly se-
lected from the AACN database; the participation request response
rate was 25 percent. Seven of the 62 programs were classified as
new and had not started to admit students at the time of data collec-
tion; they were excluded from the study. The minimum qualification
required for application to the 62 ABSN programs was a bachelor
of science degree. The overall curricular length of the participating
programs varied from 12 to 15 months. The total number of partici-
pants was 104; 82 percent were women. Participant ages ranged from
31 to 70 years,with 65percent between the ages of 51 and60 years; 57
percent had a terminal degree. Participants self-identified the predomi-
nant program in which they taught (traditional, accelerated, or both);
70 percent taught in both programs, and 20 percent taught only in ac-
celerated programs. Five faculty who reported they taught only in tradi-
tional programs did not meet inclusion criteria and were not allowed
to complete the survey. See Table 2.

One-way analysis of variance was conducted to compare the ef-
fect of affective and normative commitment on the WEC and GJS
with the following findings. There was significant effect on affective
commitment, p < .05, for the work conditions of stress and experi-
ences of shortcomings, F(23, 61) = 1.85, p = .029; general satisfac-
tion, F(24, 63) = 5.80, p = .000; managerial support, F(23, 61) = 3.38,
p = .000; professional development, F(24, 65) = 2.39, p = .003; and
GJS, F(23, 60) = 5.93, p = .000, conditions. The work condition of
communication and cooperation, F(24, 64) = 0.92, p = .578, was
not significant. Normative commitment and the WEC and GJS were
significant for the work conditions of general satisfaction, F(27,
58) = 2.57, p = .001; managerial support, F(27, 56) = 2.43,
p = .003; professional development, F(27, 59) = 2.57, p = .001;
communication and cooperation, F(27, 59) = 2.02, p = .013; and
GJS, F(27, 54) = 4.23, p = .000. Normative commitment and the work
condition of stress and experiences of shortcomings were not signif-
icant, F(27, 56) = 1.56, p = .080.

Regression and stepwise regression of affective and normative
commitment was conducted; the criterion variable and the predictor
variables were the WEC subscales and GJS Scale. Affective commit-
ment was affected by work environment subscales stress and expe-
riences of shortcomings (β = 0.347, t = 3.223, p < .01), general
satisfaction (β = 0.723, t = 8.666, p < .01), professional development
(β = 0.317, t = 2.979, p < .01), and GJS (β = 0.492, t = 3.781, p < .01)
variables. Four of the six normative commitment subscale variables
were significant: stress and experiences of shortcomings (standard-
ized B = .449, t = 4.352, p < .01), general satisfaction (standardized
B = .473, t = 2.712, p < .01), managerial support (standardized
B = .285, t = 2.091, p < .05), and professional development (stan-
dardized B = .297, t = 2.422, p < .05).

VOLUME 42 NUMBER 2 83

uthorized reproduction of this article is prohibited.

Table 2: Faculty Participant Demographics
(N = 104)

Descriptor n

Gender

Female 89

Male 12

Did not identify 3

Tenure-status

Tenured 15

Tenure track 22

Nontenured 62

Rank

Professor 9

Assistant/associate professor 70

Instructor/instructional faculty 19

Higher education years

≤5 47

6–10 24

11–20 24

21–30 7

>30 1

Predominant teaching program

Traditional BSN 5

Accelerated BSN 23

Traditional and accelerated 76

Donovan and Payne

Pearson’s correlation test was conducted; the matrix of the
statistically significant (p ≤ .01) correlations between the WEC
subscales and level of commitment are noted as follows. A
two-tailed test was used to identify the direction of the correla-
tions. Moderately strong inverse correlations were found between
the WEC stress and experiences of shortcomings subscale and
both normative, r(83) = −.374, p > .05, and affective commitment,
r(84) = −.323, p < .05. Affective commitment was correlated pos-
itively with the WEC subscales of general satisfaction, r(87) = .74,
p < .01; managerial support, r(84) = .636, p < .05; communication
and cooperation, r(88) = .29, p > .05; and professional develop-
ment, r(89) = .62, p < .05. GJS was correlated positively with af-
fective commitment, r(88) = .76, p < .05. Significant correlations
(p ≤ .05) were also observed between normative commitment

84 March/April 2021

Copyright © 2021 National League for Nursing. Una

and the WEC of general satisfaction, r(85) = .58, p < .05; man-
agerial support, r(83) = .56, p < .05; communication and cooper-
ation, r(86) = .24, p > .05; and professional development, r
(86) = .54, p < .05. However, continuance commitment was not
significantly correlated with the WEC subscales or the GJS score
(p > .05).

DISCUSSION
The MDOC model describes a connection between the individual
within the organization and the individual’s relative response to
the work environment within the organization. The model has
three dimensional levels (affective, normative, continuance) that
exist independently. A broad distinction exists between each
level and the individual’s commitment to the organization. Pur-
poseful refinement of the dimensional level of organizational com-
mitment and work environment provides clarity on the ABSN
faculty experience.

Faculty who participated in this study were both affectively and
normatively committed to the organization. Affective commitment
suggests that ABSN faculty who are highly committed to the organi-
zation are likely to stay with the organization. They are more likely to
reach out and discuss teaching and/or program challenges and work
through and address the challenges they face. Normatively commit-
ted ABSN faculty stay because it is right for them to stay. The organi-
zation has provided them with opportunities and they thus feel an
obligation to the organization. Normatively committed faculty will dis-
cuss the challenges and concerns of the program when asked; but
their connections to the organization are not as strong as those of af-
fectively committed faculty.

Specific work conditions were identified that add clarity to the
dimensional level noted by participants. WEC and GJS were stud-
ied to evaluate potential antecedents that correlate with the dimen-
sional level (affective, normative, continuance) of organizational
commitment. Consistent with the theoretical discussion by Myer
and Allen (1991), the WEC subscales identified as significant and
important to both affectively and normatively committed ABSN
faculty were the subscales of stress and experiences of shortcom-
ings, general satisfaction, managerial support, and professional
development, as well as GJS. Gutierrez et al. (2012) also noted
nurse faculty in general perceived organizational support and de-
velopmental experiences as important indicators of faculty organi-
zational commitment.

The stress and experiences of shortcomings subscale identified
the challenges faced by ABSN faculty and specifically focused on
work conditions within the ABSN program. Faculty described the
program as stressful because of the amount of planning, teaching,
and time required to implement courses. These specific characteris-
tics caused respondents to feel pressured to complete the course
and feel at risk of failure because of pressure. The program’s
fast-paced curriculum, with increased time spent in the classroom
and clinic, was noted as problematic. Promotion of a healthier or
alternative way to teach in the ABSN program could help address
this challenge. For example, where a condensed course is taught
over a shortened time period, the course could be taught by
more than one faculty member. Team teaching provides relief
for faculty and offers time to address course planning, grading,
and student advice. It also offers time to evaluate and review out-
comes through formative evaluation and address challenges in a
proactive way.

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uthorized reproduction of this article is prohibited.

ASBN Faculty Commitment

Managerial support was an additional work condition that was
correlated with affective and normative commitment. In general, par-
ticipants addressed managerial support received from leadership
that related to the faculty evaluation process. Leadership style was
identified by Byme and Martin (2014) as an important predictor
of nurse faculty satisfaction and organizational commitment.
Faculty evaluation was seen by ABSN faculty to give and receive
feedback directly from the program director/supervisor and ad-
dress challenges related to the program. The ABSN faculty were
noted to be a direct conduit for tackling the challenges of the
ABSN condensed curriculum. Active involvement by the pro-
gram’s managers and/or leaders was a positive way to address
program challenges.

Two additional work conditions that were positively corre-
lated with affective and normative commitment were general sat-
isfaction and professional development relating to the teaching,
scholarship, and service aspects of the faculty role. Participants
felt that it was important to attend and participate in faculty de-
velopment for professional growth. Wang and Liesveld (2015)
identified professional development as a way to provide greater
fulfillment for academic nurse faculty. General satisfaction was
viewed by participants as essential. Dorenkamp and Ruhle
(2019) noted general satisfaction of faculty to be a direct effect
of affective commitment to the academic organization. Areas
that participants in this study identified positively were allow-
ances for professional creativity in course teaching, positive col-
legial relationships, and job variation and the acceptance of
professional opinions.

GJS, noted by Gutierrez et al. (2012) to be a predictor of affective
commitment, was evaluated as a separate work condition from gen-
eral satisfaction. The GJS scale asks if faculty would continue to work
in this program and recommend it to other faculty. GJS as a work
condition was highly significant for both affectively and normatively
committed ABSN faculty.

The MDOC organizational commitment model provided an
opportunity to explore the challenges being faced by ABSN
faculty. The study identified that ABSN faculty presented with
affective and normative commitment levels with their level of
commitment potentially influenced by specific work environmen-
tal conditions and overall GJS. Nursing academic leadership
should continue to identify those areas within the nurse faculty
role that provide a sense of satisfaction and/or dissatisfaction in
the ABSN curricula.

Implications for Nursing Education
WEC and GJS can affect commitment to an organization. ABSN
program faculty in this study were found to be affectively and nor-
matively committed to their accelerated nursing programs. In addi-
tion, connections were found between WEC and GJS. Implications
for faculty include the need for active involvement in the organiza-
tion’s strategic vision and values, leadership/management ac-
knowledgment of high-intensity work, and recognition of faculty
contributions to the program’s success. Practical recommenda-
tions include additional workload credit for formative and summa-
tive evaluations conducted during the accelerated program;
administrative support to address faculty stress and concerns about
administrative shortcomings; of new-faculty support through an
orientation process that includes specific program insights and
teaching strategies identified by veteran faculty; and the provision

Nursing Education Perspectives

Copyright © 2021 National League for Nursing. Una

of peer support to keep faculty motivated to continue teaching in
ABSN curricula.

Recommendations for further research include the devel-
opment of comprehensive comparison between traditional and
accelerated programs and evaluation of workload, stress, and
management variances. Additional insights on the manifestation
of faculty stress in the ABSN program may provide greater insight
into the faculty role. Finally, the influence of the organizational
commitment model on well-being among ABSN nurse faculty
needs to be evaluated.

Limitations
The primary limitation of this study was the sample size. The inclusion
criteria included participants with an ABSN workload or ABSN and
traditional faculty workload. A demographic question asked about
the percentage of workload faculty taught in the ABSN program.
As participants taught in both ABSN and traditional BSN programs,
the findings may affect the generalizability of the results.

CONCLUSION
As ABSN programs continue to proliferate, it is important to continue
to evaluate the relationship between the organizational commitment
of program stakeholders and faculty health and well-being. Although
no direct causal link with faculty well-being was found, the inherent
work conditions of the ABSN program were correlated with the work
condition of stress and experiences of shortcomings. In addition,
work conditions provided recognition of the ABSN programs’ inten-
sity and challenges. Further evaluation of work conditions for faculty
teaching in ABSN programs and their potential effects on the out-
come of well-being is recommended.

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fast track to careers in nursing. https://www.aacnnursing.org/nursing-
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Brandt, C. L., Boellaard, M. R., & Zorn, C. R. (2015). The faculty voice:
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Byme, D. M., & Martin, B. N. (2014). A solution to the shortage of nursing faculty:
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Cangelosi, P. R. (2013). Teaching experiences of seconddegree accelerated bacca-
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Carver, L., Candela, L., & Gutierrez, A. P. (2011). Survey of generational aspects of
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Christoffersen, J. E. (2017). Teaching accelerated second-degree nursing students:
Educators from across the United States share their wisdom. Nursing Forum,
52(2), 111-117. 10.1111/nuf.12174

Dorenkamp, I., & Ruhle, S. (2019). Work-life conflict, professional commitment, and
job satisfaction among academics. Journal of Higher Education, 90(1), 56-84.
10.1080/00221546.2018.1484644

Downey, K. M., & Asselin, M. E. (2015). Accelerated master’s programs in nurs-
ing for non-nurses: An integrative review of students’ and faculty’s percep-
tions. Journal of Professional Nursing, 31, 215-225. 10.1016/j.profnurs.
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Gutierrez, A. P., Candela, L. L., & Carver, L. (2012). The structural relationships be-
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riences, work values, organizational support, and person-organization fit among
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Donovan and Payne

Myer, J. P., & Allen, N. J. (1991). A three-component conceptualization of organiza-
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Myer, J. P., & Allen, N. J. (1997). Commitment in the workplace: Theory, research
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Timalsina, R., Sarala, K. C., Rai, N., & Chhantyal, A. (2018). Predictors of organiza-
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ical approaches. Journal of Professional Nursing, 31(6), 482-492. 10.1016/j.
profnurs.2015.04.010

www.neponline.net

uthorized reproduction of this article is prohibited.

Week 5 ANOVA Exercises SPSS Output 

Descriptives

Overall satisfaction, material well-being

N Mean Std. Deviation Std. Error

95% Confidence Interval for

Mean

Minimum MaximumLower Bound Upper Bound

No Housing Problem 367 12.71 2.353 .123 12.47 12.95 4 16

One Housing Problem 264 11.97 2.588 .159 11.66 12.28 4 16

Two or More Housing

Problems

304 10.57 2.594 .149 10.28 10.86 4 16

Total 935 11.80 2.658 .087 11.63 11.97 4 16

Test of Homogeneity of Variances

Overall satisfaction, material well-being

Levene Statistic df1 df2 Sig.

2.109 2 932 .122

ANOVA

Overall satisfaction, material well-being

Sum of Squares df Mean Square F Sig.

Between Groups 771.072 2 385.536 61.674 .000

Within Groups 5826.111 932 6.251

Total 6597.183 934

Multiple Comparisons

Overall satisfaction, material well-being

Tukey HSD

(I) Housing Problems (J) Housing Problems Mean

Difference (I-J) Std. Error Sig.

95% Confidence Interval

Lower Bound Upper Bound

No Housing Problem One Housing Problem .739* .202 .001 .27 1.21

Two or More Housing

Problems

2.139* .194 .000 1.68 2.59

One Housing Problem No Housing Problem -.739* .202 .001 -1.21 -.27

Two or More Housing

Problems

1.401* .210 .000 .91 1.89

Two or More Housing

Problems

No Housing Problem -2.139* .194 .000 -2.59 -1.68

One Housing Problem -1.401* .210 .000 -1.89 -.91

*. The mean difference is significant at the 0.05 level.

 


Research for Evidence Based Practice 

WEEK 5

ASSIGNMENT: T-TESTS AND ANOVA


You are a DNP-Prepared nurse tasked with evaluating patient care at your practice compared to patient care at affiliated practices. You have noticed that a key complaint from your patients concerns the wait times associated with each patient visit. Based on these complaints, you have decided to compare the wait times at your practice to the wait times at affiliated practices. After recording the wait times at each practice, for 50 individual patients at each practice, you are now prepared to analyze your data. What approach will you use to analyze the data?

In the scenario provided, you might decide to use, the Analysis of Variance (ANOVA) approach.  “ANOVA is a statistical procedure that compares data between two or more groups or conditions to investigate the presence of differences between those groups on some continuous dependent variable” (Gray & Grove, 2020). ANOVA is often a recommended statistical technique, as it has low chance of error for determining differences between three or more groups.

For this Assignment, analyze the ANOVA statistics provided in the ANOVA Exercises SPSS Output document. Examine the results to determine the differences and reflect on how you would interpret these results.

Reference: Gray, J. R., & Grove, S. K. (2020). 
Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (9th ed.). Elsevier.

RESOURCES

LEARNING RESOURCES

Required Readings

· Gray, J. R., & Grove, S. K. (2020). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (9th ed.). Elsevier.

·

· Chapter 25, “Using Statistics to Determine Differences” (pp. 687–698)

· Donovan, L. M., & Payne, C. L. (2021). 
Organizational commitment of nurse faculty teaching in accelerated baccalaureate nursing programs.
Links to an external site.
 Nursing Education Perspectives,42(2), 81–86. doi:10.1097/01.NEP.0000000000000764

· Gray, J. A., & Kim, J. (2020). 
Palliative care needs of direct care workers caring for people with intellectual and developmental disabilities
Links to an external site.
. British Journal of Learning Disabilities, 48(1), 69–77. doi:10.1111/bld.12318

· Hilvert, E., Hoover, J., Sterling, A., & Schroeder, S. (2020). 
Comparing tense and agreement productivity in boys with fragile X syndrome, children with developmental language disorder, and children with typical development
Links to an external site.
. Journal of Speech, Language and Hearing Research, 63(4), 1181–1194. doi:10.1044/2019_JSLHR-19-00022  

· Document: 
Week 5 ANOVA Exercises SPSS Output 
 Download Week 5 ANOVA Exercises SPSS Output(PDF)

TO PREPARE:

· Review the Week 5 ANOVA Exercises SPSS Output provided in this week’s Learning Resources.

· Review the Learning Resources on how to interpret ANOVA results to determine differences.

· Consider the results presented in the SPSS output and reflect on how you might interpret the results presented. 

THE ASSIGNMENT: (2–3 PAGES)

· Summarize your interpretation of the ANOVA statistics provided in the Week 5 ANOVA Exercises SPSS Output document.

·
Note: Interpretation of the ANOVA output should include identification of the -value to determine whether the differences between the group means are statistically significant.

· Be sure to accurately evaluate each of the results presented (descriptives, ANOVA results, and multiple comparisons using post-hoc analysis)

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. 

image1.jpeg

Rubric

NURS_8201_Week5_Assignment_Rubric

NURS_8201_Week5_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeSummarize your interpretation of the ANOVA statistics provided in the Week 5 ANOVA Exercises SPSS Output document.

45 to >40.0 pts

Excellent

The response accurately and clearly summarizes, in detail, the ANOVA statistics provided…. An accurate and detailed explanation of the p-value describing whether the differences are statistically significant is provided.

40 to >35.0 pts

Good

The response accurately summarizes the ANOVA statistics provided…. An accurate explanation of the p-value describing whether the differences are statistically significant is provided.

35 to >31.0 pts

Fair

The response inaccurately or vaguely summarizes the ANOVA statistics provided…. An inaccurate or vague explanation of the p-value describing whether the differences are statistically significant is provided.

31 to >0 pts

Poor

The response inaccurately and vaguely summarizes the ANOVA statistics provided, or itis missing…. An inaccurate and vague explanation of the p-value describing whether the differences are statistically significant is provided, or it is missing.

45 pts

This criterion is linked to a Learning OutcomeBe sure to evaluate each of the results presented (descriptives, ANOVA results, and multiple comparisons).

40 to >35.0 pts

Excellent

The response accurately and clearly evaluates, in detail, each of the results presented in the document (descriptives, ANOVA results, and multiple comparisons).

35 to >31.0 pts

Good

The response accurately evaluates each of the results presented in the document (descriptives, ANOVA results, and multiple comparisons).

31 to >27.0 pts

Fair

The response inaccurately or vaguely evaluates each of the results presented in the document (descriptives, ANOVA results, and multiple comparisons)…. OR… The response summarizes < 3 of the results provided.

27 to >0 pts

Poor

The response inaccurately and vaguely evaluates each of the results presented in the document (descriptives, ANOVA results, and multiple comparisons), or it is missing.

40 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.

5 to >4.0 pts

Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.

4 to >3.5 pts

Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive.

3.5 to >3.0 pts

Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. … Purpose, introduction, and conclusion of the assignment is vague or off topic.

3 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time…. No purpose statement, introduction, or conclusion was provided.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.5 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.5 to >3.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

3 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.5 pts

Good

Contains a few (1 or 2) APA format errors.

3.5 to >3.0 pts

Fair

Contains several (3 or 4) APA format errors.

3 to >0 pts

Poor

Contains many (≥ 5) APA format errors.

5 pts

Total Points: 100

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