Nurse Education in Practice 13 (2013) 155e160

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Nurse Education in Practice

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Review

Perception of nursing students to two models of preceptorship in clinical training

Tagwa Y. Omer a,1, Waka A. Suliman b, *, Laisamma Thomas b, 2, Jayashanthimani Joseph b, 3
a
College of Nursing e Jeddah (CON-J), King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), National Guard Health Affairs (NGHA), Saudi Arabia
b
Nursing Department, CON-J, KSAUHS, Saudi Arabia

a b s t r a c t
Keywords: Purpose: This descriptive survey aimed at exploring nursing students perception of two models of
Preceptorship model preceptorship: Model A requires intensive mentorship while Model B requires increasing students in-
Preceptor
dependence and self directed learning.
Preceptee
Methods: Convenience sample of 110 nursing students were recruited for this study. Fifty seven who were
in courses of adult I and adult II were engaged in Preceptorship Model A, while 53 who were in courses of
maternity and pediatric nursing were engaged in Preceptorship model B. Moores (2009) reliable Pre-
ceptorship Evaluation Survey was used for data collection. It consists of three dimensions: preceptors
performance, preceptorship support at the practice site, and preceptee satisfaction with the clinical
training experience. t-test, independent samples, was used for data analysis.
Results: The ndings showed that participants mean scores on each dimension: preceptee satisfaction,
program support, as well as preceptors performance domains (teacher, facilitator, role model, provider of
feedback, adept with adult learning, advocate, and socializer) were signicantly (p < .05) in favor of
Model A.
Conclusions: Participants perceived the preceptorship model which incorporates intensive mentoring as
more satisfactory than the preceptorship model where increasing students independence and self
directed learning is required.
2013 Elsevier Ltd. All rights reserved.

Introduction To train students in the clinical area, a collaborative model was

The Kingdom of Saudi Arabia has a well knitted health care
delivery system requiring a multitude of nursing professionals. The
Kingdom is taking great initiative in training nurses as a part of
nationalizing the nursing profession.
King Saud Bin Abdulaziz University is a specialized university for
health sciences under Saudi Arabian National Guard with three
nursing colleges in three different regions. The College of Nursing
Jeddah (CON-J) is one among them which has two intakes (50 each)
per year for the BSN program.
The students have their clinical training in King Khalid National
Guard Hospital (KKNGH), Jeddah which is a JCI accredited tertiary
health care center having a bed strength of 900.
* Corresponding author. Tel.: 966 507488276 (mobile).
E-mail addresses: Omerta@ngha.med.sa (T.Y. Omer), thaherw@ngha.med.sa
(W.A. Suliman), ThomasL@ngha.med.sa (L. Thomas), ManiJO@ngha.med.sa
(J. Joseph).
1
Tel.: 966 553522293 (mobile); fax: 966 26755370x29210.
2
Tel.: 966 505217219 (mobile).
3
Tel.: 966 538884864 (mobile).
designed by the CON-J and KKNGH. The model was based on the
vision, mission and philosophy of the university, the college, and
the clinical site. In doing so, the core values of quality and excel-
lence; team work; efcient and effective resource utilization and
the focus on the client are adhered to. Both the college and the
division of nursing services are jointly responsible and accountable
for developing a competent nurse at the baccalaureate level. The
model supports the concept that the preceptors are responsible
under the faculty member for the direct supervision of the students
in the clinical setting. A Clinical Practice/Education Liaison Com-
mittee was created to facilitate co-ordination, implementation,
evaluation and communication of the activities of each party. In-
formation is provided to all nursing services employees during the
general nursing orientation and unit based information through the
Nursing Education Department. Such clinical collaborative efforts
are in line with previous researchers suggestions to establish closer
links and passion to create a positive learning environment where
all stakeholders (i.e., at universities/college and the clinical sites)
may maximize satisfaction with clinical learning experiences
(Curtis, 2007; Happell, 2009; Spurr et al., 2010; Latham et al., 2011).
This collaborative model uses two models of preceptorship
in precepting the students during their course which are

1471-5953/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2013.02.003
156 T.Y. Omer et al. / Nurse Education in Practice 13 (2013) 155e160
preceptorship model A and preceptorship model B, each is
described briey as follows:
1. Preceptorship model A is one where the preceptor is a bacca-
laureate degree holder who has been recruited and creden-
tialed by the College of Nursing as a Clinical Teaching Assistant
(CTA). She is accommodated and salaried by the college. She
commenced her work with the nursing service at the clinical
site three months before she held a teaching/training load with
the students. The CTA as a preceptor was subject to proba-
tionary requirements of the clinical specialty (i.e. meeting the
competencies in accordance with nursing service protocol at
the clinical site). Once a CTA has passed her 3-month proba-
tionary period, she is required to act in her capacity as a student
preceptor and should be available to college students during
coordinated academic semesters.
The CTA chooses two patients in consultation with the faculty
course coordinator, takes the patients from the primary nurses
for care with four students attached to her. The team of CTA and
students provide holistic nursing care from 0700 h to 1600 h
while using every opportunity to teach the student the safe
practice of comprehensive nursing care. At 1600 h patients are
transferred back to the primary nurse. This model of precep-
torship is used where intensive preceptorship is required as in
basic courses where student is exposed for the rst time to the
clinical area. This is used with courses of Adult I and Adult II.
2. Preceptorship model B is one where the preceptors are hospital
employed staff nurses of diverse nationalities, languages and
qualications. The students are attached with selected primary
nurses of a unit in consultation with the faculty (course coordi-
nator). The faculty is responsible for setting the environment to
achieve the clinical learning objectives for specic courses while
making sure that the students across the different clinical units
get the appropriate exposure. This model aimed at increasing
students independence and enhancing self directed learning, it
is used with specialty areas like Maternity Nursing, Pediatric
Nursing and Critical Care Nursing. The preceptors in each unit
have great role in precepting the student while providing holistic
care to the patient. Each preceptor is responsible to 6e7 patients
and one student. In this model, the colleges CTAs support stu-
dents whenever necessary. The CTAs do not take patients for the
delivery of care but may be involved in specic care for
demonstrating if needed. Each CTA may have to supervise more
than one unit and around 10e12 students as compared to model
A where a CTA takes 4 students in a single unit.
The preceptorship model A is used for the rst time in Saudi
Arabia to precept BSN students, where as the preceptorship model
B is the traditional and more widely used method. As this model A
is an innovation, the researchers decided to assess the perception of
CON-J students about their satisfaction with the performance of
preceptors in model A and model B.
Literature review
Empirical studies in nursing have examined different models of
precepting (Callaghan et al., 2009; Happell, 2009; Ekebergh, 2011;
Guttman et al., 2011; Latham et al., 2011); techniques used by
preceptors (Bott et al., 2011; Carlson et al., 2009, 2010); clinical
teaching and learning strategies (Khan et al., 2012); psychosocial
clinical learning environments (Henderson et al., 2006; Sharon and
Stephen, 2006); and effective characteristics of clinical teaching
(Liu et al., 2009, 2010). In general, the ndings consistently re-
ported that preceptorship models facilitate students effective
learning and practice in the clinical environment.
For example, Callaghan et al. (2009) explored the perception of
nurses one year after graduation, who experienced collaborative
learning unit (CLU) and preceptorship placements during years
three and four of their nursing program at the University of British
Columbia, Canada. Out of 37 graduates 22 of those respondents
were engaged in both models. The ndings of the study showed
that both models offered different yet complementary paths for
learning. Each model enhances professional development and
practice competency. Happell (2009) developed a model of pre-
ceptorship which reects on the interests and needs of stakeholder
groups, the model reported the positive and negative inuences to
the relationship between the preceptor and the preceptee.
Guttman et al. (2011) developed two innovative models to prepare
clinically expert faculty educators. Key components of the models
included education competency and clinical expertise. Latham et al.
(2011) study showed that a university e service mentoring pro-
gram enhanced professionalization, and contributed to improved
retention of nurses and patient care outcomes.
The literature indicates that positive studentepreceptor rela-
tionship is essential for clinical learning. Henderson et al. (2006)
studied nursing students perception of the psychosocial clinical
learning environment within three different clinical placement
models: the preceptor model, the standard facilitation model, and
the clinical education units model. They found that the most
positive social climate was associated with the preceptor model.
Sharon and Stephens (2006) study ndings are in line with Hen-
dersons. They noted that when the students saw their preceptors
participating actively and positively with them, the learning was
enhanced. Conversely, when students experienced non-positive
relationships with their preceptors, the learning was inhibited.
Bott et al. (2011) described a 5 min preceptor strategy that is
labeled as microskills model. The model includes the following
ve steps: get the student to take a stand, probe for supporting
evidence, teach general rules, reinforce the positives, and correct
errors and misinterpretations. The ndings of the ethnographic
study of Carlson et al. (2009) illustrated preceptor teaching as a
continuous process, encompassing independent steps. Open
communication on the learning needs of the student and a trustful
relation is seen as crucial to enhance student learning. Further, the
Carlson et al. (2010) study has illuminated how preceptors
behavior, words, and actions facilitate opportunities for students to
internalize knowledge, skills and ethical views. Khans (2012) study
ndings showed that demonstration was the most effective strat-
egy for improving students skills, and Spurr et al. (2010) noted that
teaching with passion results in more positive learning
environment.
Moore (2009) developed an instrument which emphasized the
multi-faceted role of the preceptor: role of a teacher; facilitator;
role model; provider of feedback; adept at using adult learning
principles; advocate; and socializer. Similar roles were reported by
Liu et al. (2009) in their qualitative study on clinical nursing pre-
ceptors perception of characteristics of effective clinical teaching.
The results emphasized willingness of the preceptor to teach, in
addition to being skillful in routine and advanced clinical tech-
niques, and being a role model. Further, Liu et al. (2010) reported
acting as a mother for students to enhance a good learning
environment as a unique nding in their phenomenological study.
An integrated review of the literature by Earle et al. (2011)
revealed that there is a need for further research in the intergen-
erational diversity of nurses and its inuence on preceptorship
experience. The study highlighted the limited research that
currently exists on the topic of intergenerational workforce. How-
ever, their study placed more emphasis on transition into practice,
recruitment and retention rather than preceptorship models and
clinical learning techniques.
 T.Y. Omer et al. / Nurse Education in Practice 13 (2013) 155e160
In conclusion, several models have been identied and exam-
ined by the reviewed literature. All models stressed positive clinical
relationships between preceptors and students to promote
accountability and to provide feedback in a supportive environ-
ment. However, all reviewed articles have been applicable to
western countries because to date, there has been no documented
literature on models of precepting students in the clinical area in
Saudi Arabia. This prompted the researchers to carry out this study.
Purpose and research questions
The aim was to explore the perception of students to two
different models of preceptorship: Model A and Model B in the
clinical training in different nursing courses namely: Adult Nursing
I, Adult Nursing II, Maternity Nursing, and Pediatric Nursing. The
variables of interest were performance of preceptors in relation to
the following domains: teacher, facilitator, role model, provider of
feedback, adept at using adult learning principles, advocate, and
socialize; support to preceptorship models by the program; and
satisfaction of preceptee with model A and model B. Specically,
this study aimed at nding answers to the following research
questions:
1. Which preceptorship model do participants perceive as
signicantly satisfactory?
2. Which preceptorship model do participants perceive as
signicantly supported by the program?
3. Which preceptor performance domains contribute to the sta-
tistical difference between preceptorship model A and pre-
ceptorship model B?
Study signicance
This study was considered signicant for the College of Nursing
management and faculty members because it may provide a
foundation to their understanding of the effectiveness of each
preceptorship model, and in setting strategies believed to alleviate
factors causing students dissatisfaction.
Methods
Study design
A descriptive, exploratory, survey study with structured ques-
tionnaire was conducted and the data was analyzed quantitatively.
Study setting, population and sample
The setting for this study was the College of Nursing e Jeddah,
offering two nursing education programs: a 4-year traditional and a
2-year accelerated Bachelor of nursing degree programs. The stu-
dents have a variety of theoretical and clinical courses typical of any
western nursing curriculums. Each semester, the nursing depart-
ment coordinates clinical training of 15-week duration with clinical
institutions. King Khaled Hospital-NGHA is a 900 bed general
hospital where the students have clinical training in different
nursing courses namely: Adult I, Adult II, Maternity Nursing, Pe-
diatric Nursing, etc.
The population in this study was nursing students, at different
levels of their nursing education. A convenience sample of 110
nursing students was used based upon the following inclusion
criteria: being trained in one of the following four clinical nursing
courses: Adult I, Adult II, Maternity Nursing, Pediatric Nursing;
willing to participate, and sign informed consent. The student was
157
excluded if she refused to sign the consent, or if she did not take, at
time of data collection, one of the aforementioned clinical nursing
courses.
The participants were divided into two groups as follows: group
I was 57 students in Adult I and Adult II who were being trained by
using Preceptorship Model A. Group II was 53 students in Ma-
ternity Nursing, and Pediatric Nursing who were being trained by
using Preceptorship Model B. It worth mentioning that all group II
participants (n 53) went through model A during their adult I and
Adult II clinical courses in the preceding year.
Instrument
Moores Preceptorship Evaluation Survey (PES) of 2009 was
used to explore preceptee satisfaction with the clinical training
experience, preceptorship support at the practice site, and pre-
ceptors performance that consists of seven domains: Teacher,
Facilitator, Role model, Provider of feedback, Adept with adult
learning, Advocate, and Socializer.
The PES is a forty one (41) items self-reported questionnaire
with a 5-option Likert e type scale, ranging from strongly disagree
to strongly agree. The scale identies the extent each of the items is
agreed or disagreed upon by the respondents. The original author
established the validity and reliability of this scale. Cronbachs
alpha ranged from .818 to .890 for each preceptor domain except for
the domain of role model, which had an alpha of .729. Moore
(2009) used this scale for gathering preceptorship evaluation data
from newly hired nurses to evaluate their preceptor, the practice
site support, and to measure their job satisfaction.
In the present study, the PES was used for nursing students to
reect on their perception to the performance of their preceptors,
the clinical training site support, and their satisfaction with their
preceptorship model. Thirty seven out of forty one items were
selected, i.e., four items in the original tool were excluded as they
were not applicable. Further, the researchers modied the wording
of fourteen (14) other items to t the clinical training situation
which nursing students experience. For example, Generally
speaking, I am very satised with this job was modied to read
Generally speaking, I am very satised with this preceptorship
model. The reliability of this adapted version of the PES was
evaluated after data collection. Cronbachs alpha ranged from .606
to .847.
Further, the questionnaire included socio-demographic data,
such as: Age, Social status, GPA, and type of nursing program. The
questionnaire had taken 40 min to complete.
Ethical consideration
A permission from concerned research committees to conduct
this study was secured rst. Prior to data collection, the re-
searcher(s) provided detailed explanations of the study; it was
emphasized that participation was voluntary, responses would
remain anonymous; and participant(s) could withdraw from the
study without repercussion.
Participants were informed that all data would be treated as
condential and only the researchers would have access to the data
collected. The consent form was prepared for signature by partici-
pants who were willing to participate.
Data collection and informed consent
Data were collected from the students at the end of two
consecutive academic semesters: May 15eJune 15, 2011, and Dec.
15eJan. 15, 2012. The researchers, in collaboration with concerned
course instructors, planned meetings with the students in relation
158 T.Y. Omer et al. / Nurse Education in Practice 13 (2013) 155e160

to days, dates, times, and venues for data collection. The students
allocated to groups of ten to twenty (10e20) each and were asked
to sign the consent and then ll in the questionnaire. The re-
searcher(s) stayed with the students and collected the question-
naire once completed.
Data analysis
Preceptorship model A
As indicated in Table 2, participants mean scores on the seven
preceptors domains ranged from 3.47 to 4.08. Two performance
domains which received highest mean scores included role model
(m 4.08, SD 1.03) and provider of feedback (m 4.00,
SD .88), however, advocate was rated as lowest (m 3.47,
SD .96).

The analysis of numerical data was carried out using SPSS
version 19. Quantitative analysis included descriptive statistics
(frequencies, percentages, mean scores, standard deviations) and
inferential statistics (i.e., t-test independent samples). Statistical
signicance level was set at p < .05.
Results
Demographics
The participants were all females. The majority were aged less
than 24 years (75.4% in model A, 62.2% in model B), single (92.9% in
model A, 77.3% in model B) and in the conventional educational
program (75.4% in model A, 62.2% in model B). Most of model A
participants (59.6%) rated their day (at time of data collection)
higher than 7 out of 10. Other details of demographics are pre-
sented in Table 1.
Preceptorship model B
As indicated in Table 2, the participants mean scores on the
seven preceptors domains ranged from 2.83 to 3.42. Role model
was rated highest (m 3.42, SD .649), however, facilitator and
advocate were rated lowest (m 2.83, SD 1.04; m 2.86,
SD .880 respectively).
Further, Table 2 show that the t-test independent samples of
mean scores of all preceptor performance domains were statisti-
cally signicant (p < .05) in favor of Model A: teacher (t-
test 3.659, df 102, p < .05); facilitator (t-test 3.425, df 103;
p <.05), role model (t-test 3.880, df 104, p <.05), provider
of feedback (t-test 4.850, df 102, p <.05), adept with adult
learning (t-test 4.124, df 102, p <.05), advocate (t-
test 3.353, df 103, p <.05), and socializer (t-test 2.600,
df 83, p <.05).
Discussion

Preceptorship satisfaction The results showed that the participants were substantially
more satised with the preceptorship model A. According to Model
The mean scores for participants satisfaction with the two A, students are supervised by preceptors who provide extensive
preceptorship models were obtained. As indicated in Table 2, par- mentoring through close guidance and assistance to students
ticipants satisfaction score with model A (m 4, SD .978) was during their rst and second semesters of clinical training at the
signicantly higher than their satisfaction score with model B hospital environment. To rationalize such a result the mean scores
(m 3.2, SD .779), (t 4.432, df 95, p < .05). of the preceptor performance domains were classied as follows to
pinpoint areas of strength and weakness: >4.0 denotes strength;
Program support <4.0 to >3.0 denotes relative strength; and <3.0 denotes weak
domains for development.
The mean score of program support to the model A (me 3.7, In model A, the mean scores on two domains namely: role
SD .721) was signicantly higher than that of model B (m 3.002, modeling and provider of feedback were reasonably strong. It
SD .663), (t 5.004, df 100, p < .05). suggest that the participants are willing to model their preceptors
clinical practice, and is indicative of preceptors who help patients
become partners in their care and who probably stay involved in
Preceptors performance
providing feedback to students. In this model the participants in
adult I had no background or experience, while those in adult II had
The mean scores for the preceptors performance of the two
marginally acceptable performance based on experience acquired
preceptorship models were obtained. The results were as follows:
while in adult I. Both were in need for close guidance and assis-
Table 1 tance, and model A suits such situation where the preceptors
Demographic characteristics of participants per each preceptorship model. provided extensive mentoring.
Variable Model A (n 57) Model B (n 53) However, in model B, the mean scores on two domains namely:
No. % No. %
facilitator and advocate showed substantial weakness. The low
score on the facilitator domain indicates a weak preceptor who may
Age:
20 yrse24 yrs 43 75.4 33 62.2 not be aware of the resources the participants are in need for, and
>24 yrs 14 24.6 20 37.7 on the advocate domain indicates a preceptor who may not keep
Social status: the interdisciplinary team aware of what the participants could do
Single 53 92.9 41 77.3 for them, and may not adjust participants assignments to meet
Married 4 07.1 12 22.6
Type of program:
their learning needs. This is not necessarily unusual because this
Conventional program 43 75.4 33 62.2 model follows the traditional preceptorship model which has been
Accelerated program 24 24.6 20 37.7 noted in the literature as challenging. For example, in this model
GPA: the preceptor is a staff nurse, who may experience exhaustion due
>4.5 5 08.7 8 15
to her multiple responsibilities, unrealistic expectations from the
4 to 4.5 13 22.8 9 16.9
3 to <4 26 45.6 29 54.7 students, and little work load relief (Callaghan et al., 2009; Liu et al.,
<3 13 22.8 7 13.2 2010). Such challenges may negatively inuence the student rela-
Rate of the day: tionship with preceptors as facilitators and advocate and hence
<5 5 08.7 7 13.2 may act as sources of clinical stressors which may inhibit clinical
5e7 18 31.5 26 49
>7 34 59.6 20 37.7
learning (Henderson et al., 2006; Sharon and Stephen, 2006;
Martos et al., 2012).
 T.Y. Omer et al. / Nurse Education in Practice 13 (2013) 155e160 159

Table 2
Summary of mean scores, standard deviations, and t-test of preceptorship model A and model B (N 110).

Study variables Model A (n 57) Model B (n 53) t-Test df p-Value

Mean SD Mean SD
Preceptorship satisfaction 4.000 .978 3.206 .779 4.432 95 <.0001
Program support 3.692 .721 3.002 .663 5.004 100 <.0001
Preceptors Performance Teacher 3.848 .982 3.228 .713 3.659 102 <.0001
Facilitator 3.536 1.06 2.830 1.04 3.425 103 .001
Role model 4.080 1.03 3.420 .649 3.880 104 <.0001
Provider of feedback 4.006 .888 3.222 .735 4.850 102 <.0001
Adept with adult learning 3.86 .897 3.236 .622 4.124 102 <.0001
Advocate 3.472 .963 2.866 .880 3.353 103 <.001
Socializer 3.820 .963 3.333 .763 2.600 83 <.011

p <.05.

The mean scores on other preceptors performance domains
namely: teacher, adept with adult learning, and socializer in both
models (A and B) were relatively strong. However, it was statisti-
cally stronger in favor of model A. This indicated that participants
feel better about the performance of their preceptors who are CTAs
in model A. Lfmark et al. (2012) reported similar ndings that
supervision by university teachers was rated more highly than
supervision by preceptors. The role of CTAs as teachers and adept at
using adult learning principles encompasses their availability and
high competency in demonstrating how to ask questions, problem
solve, use information technology for patient care. They introduce
new concepts in a way that help students integrate in their existing
knowledge base while considering the student learning styles and
allowing them the independence they needed. Moreover, the
strength of CTAs in their role as socializers, though relative, attest to
being instrumental in helping the students in establishing re-
lationships with the people who work in the unit, in adapting to
what it means to be a nurse in the clinical site, and in explaining
unit policies and procedures. These ndings are congruent with
Carlson et al. (2009) and Melincavage (2011) suggestion that
communication on the learning needs of the student and a
respectful, accepting attitude are crucial to enhance clinical
learning.
The Program support mean score was statistically signicant in
favor of Model A. It indicates that the key features of Model A allow
participants and preceptors more time to discuss their mutual
clinical practice expectations than the key features of Model B. The
continuity of participants clinical learning experiences was more
ensured in Model A than Model B. The absolute availability of such
preceptors from 0700 h to 1600 h to implement and supervise
participants educational and clinical experiences according to the
curriculum and faculty instructions may rationalize participants
perception to the signicant support of Model A by the program.
This is congruent with Warne et al. (2010) study ndings which
revealed that participants were satised with the clear support for
the clinical program. Gidman et al. (2011) emphasized the need for
multi-faceted nature of student support in practice when putting
support frameworks in place.
Conclusions and implications
In model B, the results showed substantial weakness in the
preceptors role as facilitators and advocates, which may reect a
need for development. The faculty and the preceptor should
collaborate in their efforts to maximize the potential of the nursing
student academically and clinically. Ekebergh (2011) emphasized
that preceptors should create space for every students lifeworld
and use.
The fact that model B was less satisfactory than model A is more
likely an indication that the participants may have an unrealistic
concept of what they can actually handle. Model B has been used
for third year nursing students in Maternity nursing and Pediatric
nursing courses who were at a higher skill acquisition level. This
model requires them to act as autonomous, adaptable, and advo-
cates for their patients. The ineffective transition from model A,
where extensive mentoring was required to Model B, might be one
of the factors leading to their less satisfaction with Model B.
Therefore, their sense of responsibility, ability to communicate
effectively and to discuss with the preceptor why and how certain
aspects of care were carried out may need improvement.
How well the student learns to practice their nursing skills and
use the critical thinking skills in applying theory in clinical situa-
tions depends on the effectiveness of the preceptorship model
(Kim, 2007). Model A may not be a suitable substitute hence Model
B should be revised in order to contribute to the effective transition
of the students to their expected role as professional nurses.
Further studies should be carried out to describe how pre-
ceptors in model B may effectively contribute to the clinical skills
acquisition and the professional socialization of nursing students.
Replication of this study would enhance generalizability.
Limitation
The ndings should be interpreted with caution. The use of a
convenience sample of students trained in one clinical setting and
recruited from one college of nursing, and the reliance on self-
reported questionnaire as the primary data collection tool, poten-
tially may limit the generalizability of the ndings.
Acknowledgment
The authors gratefully wish to thank Dr. Marsha L. Moore for
giving permission to use her tool. Sincere thanks to all faculty
members who contributed toward this study.
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