Development and testing of an instrument (HeSoEduCo) for health and social care educators' competence in professional education

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY-NC-ND 4.0 https://creativecommons.org/licenses/by-nc-nd/4.0/ Development and testing of an instrument (HeSoEduCo) for health and social care educators' competence in professional education © 2019 Elsevier Ltd. Accepted version (Final draft) Mikkonen, Kristina; Tuomikoski, Anna-Maria; Sjögren, Tuulikki; Koivula, Meeri; Koskimäki, Minna; Lähteenmäki, Marja-Leena; Mäki-Hakola, Hanne; Wallin, Outi; Sormunen, Marjorita; Saaranen, Terhi; Koskinen, Camilla; Koskinen, Monika; Salminen, Leena; Holopainen, Arja; Kääriäinen, Maria Mikkonen, K., Tuomikoski, A.-M., Sjögren, T., Koivula, M., Koskimäki, M., Lähteenmäki, M.-L., Mäki-Hakola, H., Wallin, O., Sormunen, M., Saaranen, T., Koskinen, C., Koskinen, M., Salminen, L., Holopainen, A., & Kääriäinen, M. (2020). Development and testing of an instrument (HeSoEduCo) for health and social care educators' competence in professional education. Nurse Education Today, 84, Article 104239. https://doi.org/10.1016/j.nedt.2019.104239 2020 Journal Pre-proof Development and testing of an instrument (HeSoEduCo) for health and social care educators' competence in professional education Kristina Mikkonen, Anna-Maria Tuomikoski, Tuulikki Sjögren, Meeri Koivula, Minna Koskimäki, Marja-Leena Lähteenmäki, Hanne Mäki-Hakola, Outi Wallin, Marjorita Sormunen, Terhi Saaranen, Camilla Koskinen, Monika Koskinen, Leena Salminen, Arja Holopainen, Maria Kääriäinen PII: S0260-6917(19)30684-7 DOI: https://doi.org/10.1016/j.nedt.2019.104239 Reference: YNEDT 104239 To appear in: Nurse Education Today Received date: 6 May 2019 Revised date: 1 September 2019 Accepted date: 8 October 2019 Please cite this article as: K. Mikkonen, A.-M. Tuomikoski, T. Sjögren, et al., Development and testing of an instrument (HeSoEduCo) for health and social care educators' competence in professional education, Nurse Education Today(2019), https://doi.org/10.1016/j.nedt.2019.104239 This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier. Journal Pre-proof Title: Development and testing of an instrument (HeSoEduCo) for health and social care educators’ competence in professional education Authors First author (corresponding author): Kristina MIKKONEN, post-doctoral researcher, PhD; Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland Mailing Address: Research Unit of Nursing Science and Health Management Faculty of Medicine P.O. Box 5000 FI90014 University of Oulu Tel.: +358 40 4113913 Email: [email protected] Twitter: @Kristinamikkon ORCID: https://orcid.org/0000-0002-4355-3428 Second author: Anna-Maria Tuomikoski, researcher, MHSc; Nursing Research Foundation; The Finnish Centre for Evidence-Based Health Care: A Joanna Briggs Institute Affiliated Group; WHO Collaborating Centre for Nursing, Helsinki, Finland; Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland Third author: Tuulikki SJÖGREN, Senior Lecturer, PhD; Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland Forth author: Meeri KOIVULA, Associate professor, PhD; Faculty of Social Sciences, University of Tampere, Tampere, Finland Fifth author: Minna KOSKIMÄKI, Doctoral candidate, MNs; Faculty of Social Sciences, University of Tampere, Tampere, Finland Sixth author: Marja-Leena LÄHTEENMÄKI, Senior lecturer, PhD; Degree Programme in Physiotherapy, Tampere University of Applied Sciences, Tampere, Finland Seventh author: Hanne MÄKI-HAKOLA, Senior lecturer, MEd; MEd; Pedagogical R&D, Tampere University of Applied Sciences, Tampere, Finland Eight author: Outi WALLIN, Lecturer, docent, PhD; Degree Programme in Social Services, Tampere University of Applied Sciences, Tampere, Finland Ninth author: Marjorita SORMUNEN, Senior Lecturer, PhD; Faculty of Health Sciences, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland ORCID: https://orcid.org/0000-0001-6330-5176 Tenth author: Terhi SAARANEN, Associate professor, PhD; Faculty of Health Sciences, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland Eleventh author: Camilla KOSKINEN, Associate professor, PhD; Faculty of Education and Welfare Studies, Åbo Akademi University, Turku, Finland Journal Pre-proof Journal Pre-proof Twelfth author: Monika KOSKINEN, Doctoral candidate, MHSc; Faculty of Education and Welfare Studies, Åbo Akademi University, Turku, Finland Thirteenth author: Leena SALMINEN, Associate professor, PhD; Faculty of Medicine, Department of Nursing Science, University of Turku, Turku, Finland Fourteenth author: Arja HOLOPAINEN, research director, PhD; Nursing Research Foundation; The Finnish Centre for Evidence-Based Health Care: A Joanna Briggs Institute Affiliated Group; WHO Collaborating Centre for Nursing, Helsinki, Finland Fifteenth author: Maria KÄÄRIÄINEN, Professor, PhD; Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland Conflict of Interest: No conflict of interest has been declared by the authors. Funding Statement: This study was funded by the Ministry of Education and Culture, Finland. Acknowledgement: The reported research is part of the TerOpe project funded by the Ministry of Education and Culture in Finland. We would like to acknowledge the Ministry for providing us the opportunity to research and extend knowledge of teacher competence. We would also like to express our appreciation to the research assistants who participated in data collection during this research. Finally, we would like to acknowledge Sees‐Editing Ltd (http://www.seesediting.co.uk) service for improving the language and helping us to communicate our findings to readers of the journal. Journal Pre-proof Journal Pre-proof Abstract Background: Health and social care education is highly important for preparing future professionals for their future roles in sustainable health and social care. However, previous studies have emphasized that health and social care educators’ competence is complex and poorly defined. Thus, there is a clear need for a psychometrically validated instrument to enable clarification and assessment of the required skills. Objective: To develop and psychometrically validate an instrument (the HeSoEduCo) for assessing health and social care educators’ competence in higher and professional education. Design: Cross-sectional study. Methods: A HeSoEduCo instrument, with items inviting 1-4 Likert scale responses, was developed, based on one systematic review and one qualitative study, then validated in terms of face, content and construct validity and internal consistency (Cronbach’s alpha values). All health and social care educators based in all 21 universities of applied sciences in Finland and seven vocational colleges were subsequently invited to participate in a large-scale application of the instrument in fall 2018. In total, responses of 390 of these educators are analyzed here. Results: The face and content validity of 71 newly developed items were assessed by experts in two evaluation rounds. The final content validity showed high scores for the instrument's relevance and clarity. Confirmatory factor analysis (to test construct validity) yielded eight factors (43-items remaining), defining the following competence areas of educators: evidence-based practice, digital collaborative learning, student-centered pedagogy, collaboration & societal, leadership & management, cultural & linguistic diversity, mentoring student into professional competence development and subject & curriculum. Cronbach’s alpha values for the factors ranged from 0.70 to 0.89. Conclusion: The instrument can be used to obtain self-evaluations of educators’ competence when assessing their general competence levels and help human resources departments and managers to identify suitable continuous education programs for their staff. Keywords: Health care, social care, instrument development, statistical testing, competence, educator Journal Pre-proof Journal Pre-proof Highlights An instrument for assessing health and social care educators' competence (the HeSoEduCo) was developed. The instrument was psychometrically tested with content and construct validity and reliability. The instrument can be used for self-evaluation of educators’ competence in eight areas including evidence-based practice, digital collaborative learning, student-centered pedagogy, collaboration & societal, leadership & management, cultural & linguistic diversity, mentoring student into professional competence development and subject & curriculum. It can provide useful information for development of programs to boost this competence, both during and after educators' graduation. Journal Pre-proof Journal Pre-proof Introduction Globally, there are high and rising shortages of health care workers. According to the World Health Organization (WHO), there was a shortfall of about 2.7 million in 2013, and this figure was predicted to rise to 12.9 million by 2035 (WHO, 2013). The cited report included stark warnings about difficulties in retaining an ageing health care population, workers taking other jobs, and failure to recruit and keep young people in the sector. At the same time there are growing needs for social care to support primary health care, especially for the elderly (Soares et al., 2018), as well as clients with chronic disease and/or critical social situations (Chapman et al., 2018). High turnover intentions were identified in the decreased interest of new health care workers to keep their demanding work. Job satisfaction and wellbeing, especially concerning nursing professions, had a high correlation with turnover intentions. (Roelen et al., 2013). Thus, appropriate education is highly important for preparing future professionals for their future roles in sustainable health and social care, promoting the sector, and retaining workers. To meet these needs, the education of future professionals in the sector requires reformation, innovative solutions and strategic vision to improve outcomes in clients' health care and educate clients to support their self-care (Konttila et al., 2018). It must also enable recruits to participate fully in all the work, leadership, education and research activities associated with a highly committed, professional and responsive workforce (Lepistö et al., 2018). Inter alia, educators need to provide strong role models in their professional conduct for the students, have adequate pedagogical competence to enhance their students' learning, utilize the most effective and engaging methods to educate and motivate students, and have strong management competence in their own work (Fowler et al., 2017). They must also be able to handle high workloads (Nilsson et al., 2017) and take responsibility for their own further continuous professional development, not only in their health and social care niches, but also as educators (McMahon, 2017). In a recent study, educators also expressed needs to adjust rapidly to changes in global socio-political environments and for collaboration between multi-disciplinary educators, organizations and students to foster improvements in sustainable health and social care (Mikkonen Journal Pre-proof Journal Pre-proof et al., 2019). They also recognized requirements for cultural awareness and ability to promote the integration of young immigrant workers in health and social care settings (Mikkonen et al., 2019). However, reductions in educational resources, due to shortages of highly qualified professionals and appropriate training, hinder educators' maintenance of competence and professional growth (Zamani-Alavijeh et al., 2019). However, previous studies have emphasized that health and social care educators’ competence is complex and encompasses diverse areas of their competence. Thus, there is a clear need for a psychometrically validated instrument to enable clarification and assessment of the required competence. Several instruments have been previously used to define certain areas of educators’ knowledge, skills and/or attitudes, but not all of the required skills and abilities, so there is a clear need to develop a new instrument for measuring all the multidimensional aspects of educators' competence (Mikkonen et al., 2018). In addition, in a very recent qualitative study, involving interviews with 48 health and social care educators, we found that educators’ competence is a complex phenomenon, encompassing at least nine dimensions (Blinded-for-review). We also recognized a need to develop a new instrument capable of identifying factors associated with their levels of competence and estimating their competence in all of the dimensions, the significance of these dimensions in their daily work and relationships among the dimensions. Background Internationally, nurse educators' competence has been precisely defined, and recognized as encompassing: theories and principles of adult learning; curricula & their implementation; nursing practice; research & evidence; communication, collaboration & partnership; ethical/legal principles & professionalism; monitoring & evaluation; and management, leadership & advocacy (WHO, 2016). We also recently identified the following dimensions of health and social care educators’ competence (in addition to the ability to practice as an educator): subject, ethical, pedagogical, management & organizational, innovation & development, collaboration; cultural & linguistic; and continuous professional development competence (Blinded-for-review). Requirements to practice as a health and social care educator are set by regulations and policies that vary among countries. Health and social care include the following professions: dental hygienist, dental technician, medical technologist, midwife, occupational therapist, optician, osteopath, paramedic, physical therapist, podiatrist, prosthetist, public health nurse, radiographer, rehabilitation counselor, registered nurse, or social service worker (University of Applied Science Act 2014/932; WHO, 2013a). In Finland, requirements for health and social care educators include a professional degree (in health or social care profession), 3 to 5 working years of work experience, and a Master's and/or Journal Pre-proof Journal Pre-proof Doctoral degree with pedagogical training amounting to at least 60 European Credit Transfer and Accumulation System (ECTS) (University of Applied Science Act 2014/932). Professional degree and working years of work experience are not applicable for school teachers for instance. For health and social care educators subject competence encompasses multi-professional knowledge, evidence-based knowledge (Koivula et al., 2011), as well as deep competence in one’s area of expertise and integration of theory in professional practice (Mikkonen et al., 2019). Ethical competence includes knowledge and application of appropriate ethical codes, human morals and ethical work practices (Salminen, 2016). Pedagogical competence has been most extensively researched (Mikkonen et al., 2018) and encompasses. This encompasses proficiency in handling: the increasing trend of digitalization in teaching and learning (Virtanen et al., 2017); studentcentered pedagogy (Zawacki et al., 2016); diverse teaching methods (Chiou et al., 2015); integration of theoretical knowledge in clinical practice and/or job-relevant competence (Pitkänen et al., 2018); evaluation, reflection and meeting needs of culturally and linguistically diverse students in an integrated fashion (Mikkonen et al., 2018; Mikkonen et al., 2019). It is also essential for educators to have skills in management & organization, innovation & development, and collaboration (in addition to competence in traditional basic pedagogy in classroom settings). In comparison, school teachers’ competence encompasses a more limited amount of areas when compared with health care educators as presented in the previous discussion: content and pedagogical knowledge; beliefs, motivation, and self-regulation (Baumert and Kunter, 2013). Burgener and Barth (2018) have further included the importance of building open learning environments by involving the community and the framing of a meaningful context for students, which results in supporting students’ competence development. Inter alia, health and social care educators are required to have competence in creativity, innovative ideas, and participation in research and developmental projects in collaboration with national and international colleagues in order to respond effectively to rapidly changing health and social care environments (Boger et al., 2018). The Study Aim The purpose of this study was to develop and psychometrically validate an instrument (the HeSoEduCo) for assessing health and social care educators’ competence in higher and professional education. The following research questions were addressed: 1) What is the face and content validity of the HeSoEduCo instrument? 2) what is its construct validity and reliability for exploring health and social care educators’ competence? Journal Pre-proof Journal Pre-proof instrument with a large number of items may involve a low percentage of variance explained by single factors (Pett, 2003). Therefore, the items of the HeSoEduCo instrument need to be revisited and possibly modified, when considering the theoretical representation of the phenomenon. Content validity, with the involvement of an expert panel on the subject, can further enhance the validity of the instrument (Polit et al., 2007). The item-to-total score correlations were tested by calculating Cronbach’s alpha values, which ranged from 0.37 to 0.83 in variation. The cut-off for items in the instrument was set at the value <0.30 (DeVon et al., 2007). The Cronbach’s alpha of factors of the instrument ranged from 0.70 to 0.89, showing that certain factors reached values of ≥0.80. These can be interpreted as wellestablished factors, and ≥0.70 as newly designed factors of the instrument (DeVon et al., 2007). The HeSoEduCo instrument presented a sufficient level of validity and reliability, despite including a large number of items and sub-dimensions (Munro, 2005). The HeSoEduCo instrument can be used to measure educators’ levels of competence and also identify relationships among the dimensions. The evidence-based practice dimension is covered by items on evidence retrieval, critical evaluation, integration of evidence to guide students and its use in practice, and knowledge development. The importance of evidence-based practice for fostering it in client care at both postgraduate (Hickman et al., 2018) and undergraduate (Fiset et al., 2017) levels is frequently discussed. Moreover, it has clear importance in practice for professionals in both health (Patelarou et al., 2013) and social care (Mullen, 2014) sectors. However, educators have been shown to lack sufficient competence in evidence-based practice, although even short targeted educational courses can significantly improve their awareness of its necessity (Nichols, 2017). In this study, pedagogical competence was split into three dimensions representing competence in a digital collaborative learning, student-centered pedagogy and mentoring students in professional competence development. This is partly because pedagogical competence of educators in health and social care essentially has an intermediate position between teaching per se and mentoring students in setting their own goals and striving to develop their careers rapidly in a self-guided manner (Cartney, 2018). They must also be familiar with uses of various kinds of digital technology with educational applications, which are being increasingly used to support, motivate and help students reach their learning goals (Koekoek et al., 2018). Collaboration & societal is covered by items concerning engagement with organizations outside educators’ own institutions, other educators and on-the-job learning placements. In professional working practice, for example clinical practice, health care professionals frequently need to Journal Pre-proof Journal Pre-proof collaborate in multi-professional teams to identify and implement optimal client care (McCarthy and DiGiovanni, 2017). Health science educators also frequently participate in research project development, collaboration and publication (Huang Schiller et al., 2017). On the European level, educators have possibilities to participate in teacher exchange programs, thereby exploiting the mobility across most of the continent enabled by the EU (Taylor and Fry, 2010). However, multidisciplinary networking in education (nationally and internationally) is a growing area of competence development (Adegbola, 2010) and regarded as an increasing necessity by educators’ themselves, as teaching resources are declining (Mikkonen et al., 2019). The leadership & management dimension of the new instrument is covered by items regarding the handling of educators' administrative tasks, knowledge of education legislation and guidelines, competence in leading people and the ability to adapt to rapid changes in educators' work. The importance of leadership and management in health care education has been emphasized recently, together with needs to develop educators’ self-management and abilities to lead efforts to address workand people-related issues (Heinistö et al., 2018). Educators also have major roles to play in the development of leadership in health care practices, for example, nurses' ability to handle the increasing authority they are receiving in advanced nursing practices (Chipps et al., 2018), and management culture in their respective disciplines (Bleich, 2018). The cultural and linguistic diversity dimension is covered by items concerning abilities to guide and sensitively treat culturally and linguistically diverse students, and collaborate with international educators. Students are becoming increasingly diverse, culturally and linguistically, in health care settings because of political changes, globalization and opening of borders between countries (Bologna, 2005). Previously interviewed educators have recognized the need for competence to integrate cultural diversity in their daily education with students and international collaborators (Mikkonen et al., 2019). In addition, health care students from non-native backgrounds face substantial challenges, especially when they leave academic environments (Pitkäjärvi et al., 2011) and enter professional practice and must develop their practical competence (Mikkonen et al., 2017). Accordingly, recent studies have strongly emphasized the need for cultural mediation by educators between students and their mentors in professional working life practices (Mikkonen et al., 2016; Mikkonen et al., 2017; Oikarainen et al., 2018). In a previous study, subject competence was defined as a separate, important dimension of health and social care educators’ role in preparing students for professional conduct (Mikkonen et al., 2019). However, in this study, items covering the subject aspect of competence highly correlated Journal Pre-proof Journal Pre-proof with items covering curricular work. Curricular competence for nurse educators has been described in detail by the WHO (2016), and defined as encompassing the ability to design, implement, and evaluate curricula by integrating evidence and engaging students in the developmental work. Broad views of degree programs also have recognized importance for providing educators with more holistic views of their own subjects and guiding them to multi-disciplinary collaboration with other educators in their daily educational work (McCarthy and DiGiovanni, 2017). Limitations The study has several limitations. First, the response rate of the study was only 18%. This may have been partly because data were collected during October-December 2018, when some of the educators may have been having a fall break (the timing of which varies across the country, complicating attempts to reach all of them). The response rate may have been higher if the data collection had started earlier. Secondly, a major cross-sectional study with international participants is needed to enhance the instrument's validity, increase understanding of its validity (and possible improvements), and acquire indications of its wider generalizability. Thirdly, the instrument includes eight sub-dimensions, which causes challenges when construct validating an instrument. The construct validity was enhanced by performing a sensitivity analysis of the instrument. Further data collection and construct validity needs to be performed to enhance the validity and reliability of the instrument. Conclusion The instrument (HeSoEduCo) developed in this study proved to be valid and reliable for measuring eight dimensions (confirmed by factor analysis) of health and social care educators' competence. The instrument has been validated in a large-scale test and is the first to provide inter-professional scope for assessment of educators' competence, to our knowledge. It was developed by developing the theoretical framework systematically, initially constructed using evidence-based knowledge from previous studies, then refined via an inductive qualitative approach, involving diverse experts to evaluate its face and content validity, and finally using reliable psychometric methods to enhance its construct validity. The instrument can be used to obtain self-evaluations of educators’ competence when assessing their general competence levels, and help human resources departments and managers to identify suitable continuous education programs for their staff. 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Zawacki, A., Knutson, M., Keohane, E., 2016. A student-centered active learning approach to teaching anemias in a medical laboratory science hospital-based program. Clinical Laboratory Science 29(2), 104-105. Journal Pre-proof Journal Pre-proof Figure 1. Path diagram for Model derived by Confirmatory Factor Analysis of HeSoEduCo scale (n=390). Table 1. Demographic information of participants (n=390) Variable n % Age in years 51 (8.54)¹ Gender Female 352 90.3 Male 36 9.2 Didi not want to indicate 2 0.5 Education Vocational college 1 0.3 University of applied sciences (Bachelor’s degree) 3 0.8 University of applied sciences (Master’s degree) 27 6.9 Master’s university degree 277 71.0 Doctoral university degree 82 21.0 Language Finnish 361 92.6 Swedish 29 7.4 Year of graduation for highest degree 2006 (7.89)¹ Teacher training (pedagogical education, 60 ECTS Vocational teacher training 139 35.6 Teacher training in health sciences 213 54.6 Teacher training in education sciences 37 9.5 No teacher training 1 0.3 Current work organization Vocational college 80 20.5 University of applied sciences 310 79.5 Work experience as an educator 14 (8.78)¹ Current teacher work field Social services 77 19.7 Healthcare 245 62.8 Rehabilitation 30 7.7 Social services, healthcare and rehabilitation 38 9.8 Job description Part-time educator 12 3.1 Full-time educator 64 16.4 Lecturer 267 68.5 Principle lecturer 38 9.7 Head of degree program 9 2.3 ¹Mean (standard deviation) Journal Pre-proof Journal Pre-proof Table 2. HeSoEduCo scale’s items (n=390) Factor representing competence areas of educators Items Mean (standar d deviation ) Skewnes s Kurtosi s Cronbac h alpha if item deleted Item to total correlatio n COMPETENCE IN EVIDENCEBASED PRACTICE (α=0.84) 1. I can search for research evidence from the most common databases independe ntly (i.e. Pubmed, Cinahl, Medline). 3.55 (0.67) -1.36 1.09 0.81 0.68 2. I can critically evaluate the validity of research. 3.57 (0.55) -0.87 -0.26 0.81 0.67 3. I can identify the process of evidencebased practice (search for evidence, implement ation and evaluation) . 3.50 (0.65) -1.07 0.47 0.82 0.57 4. I can explain the importance of evidencebased practice in social and health care. 3.72 (0.51) -1.81 3.10 0.82 0.58 5. I can guide students in finding the best possible knowledge for 3.66 (0.50) -1.01 -0.19 0.82 0.62 Journal Pre-proof Journal Pre-proof decision making (e.g. clinical practice guidelines, summarize d evidence). 6. I utilize evidencebased knowledge in my teaching (e.g. clinical practice guidelines, reviews). 3.80 (0.41) -1.70 1.53 0.82 0.58 7. I can produce scientific knowledge. 3.36 (0.64) -0.61 -0.05 0.83 0.50 8. I continuousl y follow scientific publication s in order to develop my competenc e. 3.24 (0.72) -0.59 -0.19 0.84 0.47 COMPETENCE IN DIGITAL COLLABORATIV E LEARNING (α=0.89) 9. I can use a variety of tools for collaborativ e work and interaction in virtual learning. 3.03 (0.73) -0.24 -0.54 0.85 0.83 10. I can design virtual learning that promotes students’ collaborativ e building of 3.08 (0.76) -0.42 -0.40 0.85 0.83 Journal Pre-proof Journal Pre-proof Table 3. Confirmatory Factor Analysis goodness of fit index Fit indexes Statistical values Statistically recommended cut-point Chi-square 1936.406 <0.001 RMSEA (90%CI) 0.051 < 0.08 SRMR 0.059 < 0.08 CFI 0.877 > 0.90 TLI 0.867 > 0.90 CD 1.000 RMSEA, Root Mean Square Error of Approximation; SRMR, Standardized Root Mean Residual; CFI, Comparative Fit Index; TLI, Tucker-Lewis Index; CD, Coefficient of Determination Journal Pre-proof Figure 1