Michigan Primary Care Nurse Practitioner Attitudes Towards Depression

Table of Contents

Page

List of Tables…………………………………………viii

List of Appendices………………………………………ix

Chapter

One: Introduction………………………………………..1

Two:  Literature Review……………………………………4

Three: Methodology………………………………………1

Four:  Results………………………………………….1

Five:  Conclusions……………………………………….4

Six:  Implications………………………………………..1

Appendices…………………………………………..iv

References……………………………………………iv

List of Tables

1. Frequencies and percentages of responses for professional confidence subscale…..1

2. Frequencies and percentages of responses for the Therapeutic Optimism subscale…4

3. Frequencies and percentages of responses for the Generalist Perspective subscale…1

4. Mode, means, and standard deviations for professional confidence subscale…….4

5. Mode, means, and standard deviations for therapeutic optimism subscale………1

6. Mode, means, and standard deviations for generalist perspective subscale………4

Chapter One

Introduction

Depression is a chronic health condition that is prevalent, costly, and a cause of disability.  According to the National Alliance of Mental Health [NAMI], (2016), approximately 25 million people are affected by major depression in the United States.  The Diagnostic and Statistical Manual of Mental Disorder, fifth edition (DSM -5) lists the criteria that healthcare professionals use to diagnose major depression (NAMI, 2016).  For a person to have a diagnosis of major depressive disorder under the DSM-5 criteria they have to have five or more of the nine symptoms.  The nine symptoms include depressed mood, loss of interest, change in weight or appetite, insomnia or hypersomnia, psychomotor retardation or agitation, loss of energy or fatigue, worthlessness or guilt, impaired concentration or indecisiveness, and thoughts of death or suicidal ideation.  One of the symptoms must be depressed mood or loss of interest in the same 2-week period (Institute of Clinical Systems Improvement, 2016).  Depression can affect people of any age, present with different symptoms, and have negative effects if not treated.  Symptoms of depression can be mild or moderate to severe and if left untreated can lead to suicide, substance abuse, decline in health condition, decreased quality of life, and functional decline (NAMI, 2016).  Causes of depression include genetics, trauma, life circumstances, medications, drugs, and alcohol.  Depression can also occur because of a medical condition such as stroke, heart attack, cancer, or diabetes (NAMI, 2016).  Depressive symptoms describe the presence of symptoms that do not reach the DSM-5 criteria for any of the included depressive disorders.

Depression is one of the reasons why patients visit primary care in the United States (Haddad et al., 2012).  According to the American Psychological Association (2016), one in every four patients who visit primary care suffers from depression.  Moreover, most patients with depression do not use mental health services leaving a majority of them seeking treatment in primary care (Burman, McCabe, & Pepper, 2005; Richards, Ryan, McCabe, Groom, & Hickie, 2004).  In the Unites States, the third most common reason for hospitalization for people ages 18 to 44 is major depression (NAMI, 2016).  According to McTernan, Dollard, and LaMontagne, (2013), workers diagnosed with depression have missed workdays and decreased work productivity and this has a negative effect on an organization’s finances.  A study by Beck et al. (2011) also found that people with more depressive symptoms had the lowest work productivity but also found that people with minor levels of depression were also associated with some loss of work productivity.  One recommendation made from this study is that employers should provide treatment to employees diagnosed with depression to reduce the financial burden of depression regardless of the severity of depression.  Nurse Practitioners (NPs) are increasing becoming the healthcare providers in primary care making them likely to be first point of contact for patients with major depression who seek treatment with their own doctor.  This makes it important to investigate their attitudes towards managing depression.

Significance

Nurse Practitioners can provide high quality and cost effective treatment to patients with major depression in primary care (Bauer, 2010; Burman, McCabe, & Pepper, 2005; Groh & Hoes, 2003).  NPs can perform medical and psychological assessments, diagnose and treat acute and chronic conditions, order tests and interpret results, prescribe medications, counsel, educate patients about disease prevention and management, and refer patients to specialists (AANP, 2016).  In recent years, there has been an increase in the number of NPs working in primary care to help care for people with chronic illness such as depression.  According to the American Association of Nurse Practitioners [AANP], (2016), 83.4% of NPs are certified in an area of primary care.  Additionally in 2012, the Health Resources and Services Administration (HRSA) conducted a National Sample Survey of Nurse Practitioners; of the 154,000 nurse practitioners, surveyed 60,407 were working in primary care practices or facilities.  It is logical to assume that they will be the healthcare providers providing care to increasing numbers of the depressed patients in primary care.

Early identification of depression is vital to providing treatment and preventing negative effects of depression such as suicide.  According to the American Association of Suicidology (2014), major depression is a psychiatric disorder that is commonly associated with suicide.  In 2014, suicide was the tenth leading cause of death among Michigan residents per 100,000 people in the state (Michigan Department of Health and Human Services, 2014).  The American Psychiatric Association (2016) provided guidelines that providers are recommended to use in the treatment of major depression.  According to the National Institute of Mental Health (2016), there are several treatment options available for treatment of major depression.  Treatment options include antidepressants, psychotherapy such as cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy, the combination of medications and psychotherapy, group therapy, and electroconvulsive therapy (ECT).  Despite the availability of these treatment options depression continues to be misdiagnosed, untreated, and undermanaged due to lack of proper screening of patients seen in primary care and barriers health providers face when attempting to treat major depression (Groh & Hoes, 2013; Pepper, Nieuwsma, & Thompson, 2007; Weich, Morgan, King, & Nazareth, 2007).

In addition, studies done to assess attitudes towards depression using the Depression Attitudes Questionnaire indicated that primary care providers have negative attitudes towards depression (Botega & Silveira, 1996; Kerr, Blizard, & Mann, 1995; Norton et al., 2011).  Haddad et al. (2012), stated that “the attitudes of clinicians are likely to be an important factor influencing the way that they assess and respond to patients’ psychosocial problems and their willingness to adopt new approaches to this part of their work” (p. 122).  Therefore, an assessment of current attitudes of Michigan NPs working in primary care is an important start that identified the need for education to promote adequate management of depression and ensure positive patient outcomes.  This study’s results provided evidence based data on attitudes of current NPs working in primary care that can be used to guide education on how to change attitudes of current and future NPs.  Prevention of the effects of depression such as suicide, disability, and financial burden begins with effective assessment of depression, and appropriate treatment.

There is limited research regarding attitudes and beliefs of United States NPs towards depression.  Surveying NPs working in primary care using the Revised Depression Attitude questionnaire (Haddad, Menchetti, McKeown, Tylee, & Mann, 2015) allowed the researcher to assess their attitudes towards depression.  It is important to focus on depression in primary care because it is the place most patients seek help and early detection of depression is important for its proper management.  Nurse Practitioners play a vital role in caring for patients with depression and no survey has been conducted to examine Michigan NPs’ attitudes towards depression, hence the interest of this study.  This study contributes to nursing knowledge by building on current research related to attitudes towards depression.

Purpose of Study

With more patients seeking treatment for depression in primary care, it is important to have a clear picture of NPs attitudes towards depression.  According to Fussman, DeGuire, McCloskey, Hodges, and Lyles (2011), 9.4% of Michigan adults have major depression.  Proper depression management is important to ensure positive patient outcomes.  The purpose of this study was to identify Michigan primary care NPs attitudes towards depression.  Data obtained from the study helped to identify a need for NPs education on depression management.  NPs should be able to recognize depression, provide intervention, and refer patients to a specialist if needed.

Research Question

What are the current attitudes of Michigan primary care NPs towards depression?  This quantitative descriptive study assessed their current attitudes towards depression using the Revised Depression Attitudes Questionnaire.  The scores from the questionnaire provided quantitative data that identified what their attitudes are.

Chapter Two

Literature Review

A search of databases was conducted that included CINAHL, PubMed, Google Scholar, and Psychinfo.  The search terms used included depression, depression management, attitudes, nurse practitioners, primary care providers, general practitioners, and depression attitude questionnaire.  Searches were limited to English and peer reviewed journals published in the years 1990 to 2016.  Multiple searches were performed with different search terms in the above databases.  There were limited articles solely focused on nurse practitioners (NPs).  Therefore, most of the articles reviewed focus on the role of the primary care provider or the general practitioner and the use of the depression attitude questionnaire to assess attitudes towards depression but not on the role of the NP.  Based on the literature reviewed, the articles suggested that depression is not well managed due to attitudes of healthcare providers, comfort level when caring for patients with depression, barriers to depression management, and lack of depression screening.  These four themes are explored.

The relationship between attitudes and depression was the first theme identified.  In a study by Norton et al. (2011), the Depression Attitude Questionnaire (DAQ) was sent to approximately 5000 French family practitioners to evaluate attitudes and beliefs towards depression, 468 NPs (9%) completed and returned the DAQ.  The study results revealed that French family practitioners had a neutral position on professional ease when dealing with depressed patients, positive view on the origin of depression and belief that it is necessary to use antidepressants as a treatment for depression (Norton et al., 2011).  In addition, the study showed that training family practitioners in mental health through continuing education and postgraduate training improved attitudes towards depression.  In a similar study by Burman et al., (2005), the Depression Attitudes Questionnaire was administered to 108 advanced practice nurses (APN) in Wyoming to determine providers’ attitudes towards depression and mental illness.  Fifty-two surveys were returned for a return rate of 55.3%.  Findings from the study showed that APNs had a fairly moderate attitude towards pharmacological treatment of depression, and were neither uneasy nor overly confident or comfortable about caring for patients with depression.

Kerr et al., (1995) compared attitudes of general practitioners and psychiatrists in Wales, England.  The DAQ responses were received from 74 practitioners (60%) and 65 psychiatrists (67%).  Results of the study showed that general practitioners had a more negative attitude than that of psychiatrists when dealing with patients with depression and identification of depression.  General practitioners were less confident when dealing with depressed patients and found the work harder and less rewarding when compared to psychiatrists.  The authors of this study indicated that the DAQ is reliable and might be a useful tool to identify education needs to improve identification and management of depression in primary care.

Botega and Silveira (1996) conducted a study in Brazil that identified attitudes of 110 general practitioners.  The study also used the DAQ and 78 practitioners completed it for a return rate of 70%.  Seventy one percent of the participants reported difficulty identifying depression.  The study results support the need for additional education to increase knowledge on identification and management of depression of general practitioners.

The second theme addressed the lack of comfort with depression management.  The literature review revealed that NPs lack the appropriate education to diagnose and manage patients with depression thus the lack of comfort with managing depression.  Groh and Hoes (2003) sampled 3000 NPs from the membership of the American Academy of Nurse Practitioners on assessment, diagnosis, and treatment options of depressive symptoms in women.  One thousand six hundred and forty seven surveys competed, for a return rate of 55%.  The study revealed that NPs used multiple assessment tools to assess for depression and considered different factors prior to determining the appropriate treatment of depression.  In this study, 65% of the NPs felt that they were adequately prepared to assess and diagnose depression and 51% believed that they had adequate knowledge to treat depression.

In a study by Pepper, Nieuwsma, and Thompson (2007), 554 DAQ were mailed to primary care providers and 180 were returned, response rate of 32%.  The study was conducted in a rural area in Wyoming.  The purpose of the study was to examine whether rural primary care providers’ attitudes towards depression are associated with their reports of assessment and treatment of depression.  The study identified that providers who reported unease with patients with depression were less likely to assess for symptoms of depression or provide counselling or referrals to see a psychiatrist.  This shows that training of primary care providers including NPs should focus on their assessment of depression and adequate provision of treatment.

Barriers to depression management in primary care, was another theme in the literature reviewed.  A study by Burman et al. (2005) investigated the treatment practices and barriers for depression and anxiety treatment of NPs in Wyoming.  One hundred and eight questionnaires on barriers to depression treatment were mailed and 52 advanced practice nurses returned the questionnaire, return rate of 48%.  The top barriers identified by over 25% of the participants included lack of insurance, inadequate insurance and inadequate mental health providers for referral.

Richards, Ryan, McCabe, Groom, and Hickie (2004) investigated the barriers to effective management of depression and attitudes towards depression in general practice in Australia.  Four hundred and twenty general practitioners completed the survey on perceived barriers that limit their ability to care for patients with depression.  There were several barriers identified in the study; over 50% of the participants identified lack of access to mental health, inadequate allocated consultation time, and poor reimbursement of time spend managing depression.  Perceived barriers by 30% of the participants included patients’ reluctance to see a specialist, limited office time, management of presenting problems limits time on depression

Depression screening of patients in primary care is not performed given the multiple chronic comorbidities making caring for these patients’ complex and the workload prevents attention to depression (Richards et al., 2004).  In a study by Pepper et al. (2007), questionnaires were sent to 554 primary care providers and 180 returned the questionnaires, only 32% of the respondents reported using a screening instrument to help detect depression.  Another study by Groh and Hoes (2003), 33% of NPs used a standardized depression tool such as Beck Depression Inventory to screen for depression.

Conclusion

Studies have been conducted to identify attitudes of primary care providers towards depression (Botega & Silveira, 1996; Burman et al., 2005; Groh & Hoes, 2003; Norton et al., 2011; Pepper et al., 2007 and Richards, Ryan, McCabe, Groom, & Hickie, 2004).  Despite availability of several treatment and interventions to manage depression, research shows that depression is under identified and under-managed.  The research reviewed indicates the need for accurate diagnosis, increased screening, and treatment of depression to prevent its effects on patients, their families, society, and the economy.  According to the U.S Department of Health and Human Services, Health Resources and Services Administration (2010), almost half of the recently licensed NPs are joining primary care.  This indicates that NPs are more likely to be providers to treat depression in primary care.  This places importance on NPs attitudes towards depression.  The most important point in the literature reviewed is that primary care providers have negative attitudes towards treating and managing depression.  The purpose of this study is to identify Michigan primary care nurse practitioners attitudes towards depression.

Theoretical Framework

Albert Bandura’s Self Efficacy theory provides a conceptual framework for analyzing nurse practitioner attitudes in management of depression in clinical practice.  Self-efficacy theory was developed from Bandura’s social learning theory; it is the belief that people can exercise influence over their behavior to produce a desired outcome (Bandura, 1977).  People with high self-efficacy believe they can perform well given a task and are likely to view a difficult task as something to be mastered not avoided, while people with low efficacy avoid challenges and view them as beyond their capabilities (Bandura, 1977).  The belief that people with high self-efficacy hold influence on what they feel and think about others, thus motivating them to action.  Bandura identified the major sources of self-efficacy as performance mastery, vicarious experience, social persuasion, and emotional arousal (Bandura, 1977).

Nurse practitioners in primary care can evaluate their practice of depression management through the application of self-efficacy.  NPs who have high efficacy are capable of performing a given behavior are often found to be socially engaged in rendering supportive services to depressed patients more frequently than those ones who feel unskilled.  Self-efficacy in diagnosing and treating depression has been found to predict whether primary care clinicians view depression as important and frequent problem in their practice (Pepper et al., 2007).  NPs with high self-efficacy on depression management are more likely to screen patients for depression and provide treatment to depression patients compared to those with low self-efficacy (Pepper et al., 2007).  Richards et al. (2004) surveyed primary care practitioners to rate their level of self-efficacy in relation to assessment and treatment of depression.  Findings of the study showed that 90% of the 420 practitioners that participated were confident in treating depression with medication.  Seventy percent of practitioners were confident recognizing suicide, assessing degree of suicide risk, and working with other mental health professionals.  Only 30% of practitioners were confident conducting non – pharmacological interventions for drug and alcohol problems and treating depression with evidence based psychological treatments.

With increasing number of patients presenting to primary practice with depression, NPs should master depression assessment and have the adequate knowledge, and positive attitude to care for these patients and ensure they get the treatment they need to reduce all the debilitating effects of depression.  The management of depression can be complex, NPs should have confidence to screen patients for depression and provide treatment.

Chapter Three

Methodology

The purpose of this study was to identify Michigan primary care nurse practitioners (NPs) attitudes towards depression.  This chapter discusses the design, sample, data collection, instrument, protection of human rights, data analysis, and study limitations.

Design

A descriptive cross-sectional research design was used to assess the attitudes of Michigan NPs working in primary care towards depression.  Polit and Beck (2012) stated, “The purpose of descriptive studies is to observe, describe, and document aspects of a situation as it naturally occurs” (p. 226).  This design was appropriate for this study because data could be reliably collected using a self-report questionnaire and analyzed for attitudes towards depression.  Self-report questionnaires are cost-effective and efficient.  The study is cross-sectional in nature as data was collected at one point in time per participant (Polit & Beck, 2012).

Sample

The target population for this study was a convenience sample of 1134 NPs obtained from the Michigan Council of Nurse Practitioners (MICNP).  Inclusion criteria for participation included participant above 18 years of age, a member of MICNP, currently working in primary care, and have internet access.  There are 6726 licensed Nurse Practitioners according to Michigan department of licensing and regulatory affairs (2016) and 1134 NPs are members of MICNP.  Of these, just less than half (n=511) work in primary care thus the sample size of this study.  The sample represented NPs working in different primary cares across Michigan.  An estimated response rate of 10% reduced the sample to 51 completed Revised Depression Attitude Questionnaires (R-DAQ).  In a similar study about barriers to depression and anxiety treatment and attitudes towards depression by Burman, McCabe, and Pepper (2005) a sample of 94 advance practice nurses in Wyoming was used.

 Data Collection

Data collection began when the director of MICNP sent out the recruitment email to all 1134 Nurse Practitioners.  The recruitment email (Appendix A) explained the purpose of the study, why participants were chosen to complete the study, and my contact and advisor information.  If the NP chose to participate in the survey, he/she clicked on the hyperlink to Survey Monkey provided.  The link routed the participant to the demographic form (Appendix B) that included age, years of experience as a nurse practitioner, and if they are currently working in primary care.  Once the demographic form was completed those that clicked that they worked in primary care had a link to complete the R-DAQ (Appendix C).  Only completed surveys in their entirety were used in final data analysis.

Instrument

To assess the attitudes of NPs towards depression the R-DAQ was administered with permission of Dr. Mark Haddad [personal communication, March 18, 2016], (Appendix D).  The R-DAQ included 22 questions for which participants were asked to indicate level of agreement using a 5-point Likert scale and response options were 1 = Strongly disagree, 2 = Disagree, 3 = Neither disagree nor agree, 4 = Agree, and 5 = Strongly Agree.  Scores can range from 22 to 110, with a low score indicating a negative attitude towards depression.  Overall reliability of this questionnaire has been identified through an internal consistency of Cronbach’s alpha 0.80 (Haddad, Menchetti, McKeown, Tylee, & Mann, 2015) when used with a sample size of 167 general practitioners and adult nurses.  Psychometric results of the R-DAQ ranged from 57 to 110, the mean value was 87.74, median 88, and standard deviation 9.84 (Haddad et al., 2015).  Concerns about the psychometric adequacy of the DAQ and its construction to be used with a specific group of health professionals in a specific setting in the UK led to the revisions of the Depression Attitude Questionnaire (DAQ).  The R-DAQ was revised from the original DAQ using previous studies that had used DAQ to make it more useful to use with different healthcare professionals outside the United Kingdom (Haddad et al., 2015).  The panel of experts considered attitude dimensions, content, and item wording and after an agreement of greater that 70% the tool was tested (Haddad et al., 2015).

According to Haddad et al. (2015), the R-DAQ has three subscales: professional confidence, therapeutic optimism, and generalist perspective about depression.  The first subscale, professional confidence, comprised of seven items (questions 1, 7, 8 11, 15, 17, and 19) assessed confidence and feeling comfortable as a practitioner to provide depression care.  The Cronbach’s alpha coefficient for the subscale was 0.81.  The second subscale is therapeutic optimism about depression consists of 10 items (questions 3, 4, 5, 6, 9, 12, 13, 18, 20, and 21) that were reversed scored and identified negative statements about depression and its treatment, with a Cronbach alpha coefficient of 0.76.  The last subscale consisted five items (questions 2, 10, 14, 16, and 22) and identified generalist perspective about depression occurrence, recognition, and management with a Cronbach alpha coefficient of 0.62 (Haddad et al., 2015).

To establish content and face validity, three nurse practitioners were asked to read the questionnaire to ensure that the questions were consistent with attitudes towards depression.  The three NPs had an average experience of five years working with depressed patients in primary care.  Feedback was received from the three NPs that questions in the R-DAQ were related and consistent with the topic of depression.  According to Haddad et al. (2015), the R-DAQ has a Flesch reading Ease Score of 46.7 and a Flesch Kincaid Grade level of 9.4.  These scores indicate that the questionnaire is easily understandable.  The average time taken by the three nurse practitioners to complete the questionnaire was less than five minutes, therefore five minutes was chosen as the appropriate time it will take participants to complete the survey.

Protection of Human Subjects

To ensure protection of the participants’ minimal risk, Institutional Review Board exempt approval was granted by Saginaw Valley State University to conduct the study (Appendix E).  The purpose of the study and my contact information were emailed to the participants.  Completion of the survey constituted informed consent.  The participants were informed that participation was voluntary, they can opt out of the survey at any time without penalty, and no compensation would be received for completing the survey.  All surveys were made anonymous, as the surveys were completed via Survey Monkey with an IP address block enabled using SSL encryption and took approximately 5 minutes to complete.  Participants were informed of the potential risk for breach of confidentiality.  Confidentiality was protected to the extent allowed by law and results of the study were published with no identifying information.  There is also a psychological risk of discomfort related to the NPs answering questions about their practice of treating depression patients.  Only the researcher had access to the data.  Lastly, all data collected will be kept confidential and secured for 3 years and then destroyed appropriately (paper documents shredded and computer data files erased).

Data Analysis

The Statistical Package for Social Sciences Program (SPSS) at Saginaw Valley State University was used for data analysis.  Data was analyzed using descriptive statistics: means, frequencies, standard deviation, and correlations.  Correlations were done to see if there were any relationships between ages, years of experience as a NP, and attitudes towards depression.  The three subscales of the questionnaire professional confidence, therapeutic optimism, and generalist perspective about depression were correlated with each other.  Results from the statistical analysis were used to describe attitudes of NPs towards depression and answer the following possible hypotheses: NPs who reported professional confidence were more likely to report higher therapeutic optimism and NPs who reported professional confidence reported high generalist perspective about depression occurrence, recognition, and management.  Demographic data was used to describe the sample and reported as a frequency and percentage.  The R-DAQ was scored using the Likert scale 1 = Strongly disagree, 2 = Disagree, 3 = Neither disagree nor agree, 4 = Agree, and 5 = Strongly Agree.  All questions were scored as above except 10 questions that concern therapeutic optimism about depression (questions 3, 4, 5, 6, 9, 12, 13, 18, 20, and 21) that were reverse scored (Haddad et al., 2015).  Reverse scoring of the Likert scale was scored in the opposite direction: Strongly disagree = 5, Disagree = 4, Neither disagree nor agree = 3, Agree = 2 and Strongly agree = 1.

Chapter Four

Results

This chapter discusses findings of the research question “What are Michigan primary care nurse practitioner attitudes towards depression?”  This field study used a quantitative cross sectional descriptive design and data were obtained from a sample of nurse practitioners (NPs) who are current members of Michigan Council of Nurse Practitioners (MICNP) and completed an online survey that was conducted via Survey Monkey.  The Statistical Package for the Social Sciences (SPSS) version 24 was used to perform statistical analyses.  Descriptive statistics and Spearman’s correlation were used to analyze the data.

Sample

All 1134 NPs who are current members of MICNP were invited to participate in the study.  Of the 1134 members, only 511 members work in primary care.  During the four-week period that the survey was opened, 74 primary care NPs who met inclusion criteria completed the survey for a return rate of 14.5%.  The first part of the survey inquired about participant’s age and years of experience as a nurse practitioner.  The majority of respondents were in the 51-60 age category (n = 19, 25.7%), followed by ages > 60 (n = 15, 20.3%), ages 31-40 and 41-50 categories which both had the same number of participants (n = 14, 18.9%).  Least number of participants were ages 41-50 category (n = 12, 16.2%).  Data showed 21 (28.4%) with 1-5 years of experience as an NP; 16 (21.6%) with 6-10 years; 37 (50 %) with more than 10 years as an NP.

Overall Scoring

The instrument used in this study was the Revised Depression Attitude Questionnaire (R-DAQ) which contained 22 questions (Haddad et al., 2015).  All 22 questions were scored using a Likert scale 1 = Strongly disagree, 2 = Disagree, 3 = Neither disagree nor agree, 4 = Agree, and 5 = Strongly Agree.  All questions were scored as above except 10 questions ( 3, 4, 5, 6, 9, 12, 13, 18, 20, and 21)  scored using reverse scoring; Strongly disagree = 5, Disagree = 4, Neither disagree nor agree = 3, Agree = 2 and Strongly agree = 1.  Data analysis included calculating frequencies and percentages of responses for each question and calculating modes to determine number of participants for each of the 22 questions, means to determine participants’ attitude towards each question, and standard deviations for each question to determine the uniformity of participants’ responses to the questions.  Tables 1, 2, 3 show the summary of the frequencies and percentages of the responses by subscales and Tables 4, 5, 6 show the summary of the mode, means, and standard deviations by subscales.

TABLE 1: Frequencies and percentages of responses for professional confidence subscale.