organization socialization case study

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Pathways through organizational socialization: A longitudinal qualitative study based on the psychological contract

Chris woodrow.

1 Henley Business School, University of Reading, UK

David E. Guest

2 King's Business School, King's College London, UK

In this study, we explore different pathways during organizational socialization through the lens of the psychological contract using in‐depth longitudinal qualitative methods. Analysis of 112 critical incident interviews with 27 newcomers across their first year of work reveals five distinct psychological contract pathways through socialization, within which fulfilment and breach influence adjustment by facilitating or restricting opportunities to learn and integrate, as well as influencing attitudes and behaviour. The analysis reveals that whilst perceived psychological contract fulfilment facilitates newcomer adjustment, perceived breach can disrupt the process. We provide a detailed account of the way socialization and the psychological contract unfold for newcomers over time, and show that psychological contract events can significantly alter the course of adjustment.

Practitioner points

• Delivery of perceived promises that are of particular importance to newcomers during early tenure can accelerate adjustment. Managers should therefore attempt to find out which promised contributions are important to employees and prioritize their delivery.
• The negative effects of perceptions of broken promises on newcomer adjustment may be reversed by later delivery. Managers should explain the reasons for any broken promises and seek to fulfil them in the future.
• Ongoing support from managers can help newcomers to negotiate the difficult period after organizational entry, even where promises are perceived to have been broken.
• Direct managers should be made aware of information provided and promises made to newcomers by those responsible for recruitment.

Organizational socialization has been defined as ‘the process through which a new organizational employee adapts from an outsider to integrated and effective insider’ (Cooper‐Thomas & Anderson, 2006 , p. 492), which is at its most intense in the initial weeks and months after entry (Van Maanen & Schein, 1979 ). Socialization has been characterized as a time of insecurity, during which newcomers attempt to cope with (Ellis et al ., 2015 ) and reduce (e.g., Lester, 1987 ) stressful uncertainty.

The literature to date indicates that successful socialization results in adjustment, which involves developing sufficient knowledge, clarity, and confidence (Bauer, Bodner, Erdogan, Truxillo, & Tucker, 2007 ) about the new role, team, and organization to perform job requirements effectively (Haueter, Macan, & Winter, 2003 ); achieving acceptance from insiders (Moreland & Levine, 1982 ; Ostroff & Kozlowski, 1992 ); and developing stable and positive work‐related attitudes (Saks, Uggerslev, & Fassina, 2007 ). Current research has identified several factors that influence adjustment, including the methods used by organizations to facilitate socialization (Jones, 1986 ) and proactive newcomer behaviour (Saks, Gruman, & Cooper‐Thomas, 2011 ). The psychological contract, which develops during socialization (Rousseau, 1990 ), also drives employee attitudes at this time (e.g., Lapointe, Vandenberghe, & Boudrias, 2013 ).

We provide a detailed account of newcomers’ socialization experiences across their first year of work, based upon psychological contract theory and using intensive longitudinal qualitative methods. In doing so, we aim to contribute to the literature in two areas.

Existing studies have uncovered a variety of antecedents and consequences of adjustment, often based upon quantitative designs that imply a ‘stable set of forces that steadily push and pull on newcomers’ (Ashforth, Sluss, & Harrison, 2007 , p. 6). Beyond this, several studies have identified some relatively short‐term issues that indicate non‐linear forms of adjustment, such as conflicts, using quantitative methods focusing on very early socialization (e.g., Nifadkar & Bauer, 2016 ) or qualitative methods with single data collection points (e.g., Gundry & Rousseau, 1994 ; Korte & Lin, 2013 ). What is lacking is a detailed understanding of the unfolding process of adjustment, and the dynamic processes that help to determine the effectiveness of socialization. If socialization is not always a smooth process, clearer understanding is required of the different pathways that newcomers experience across socialization, and the type of events that may act as potential turning points in these pathways. This research therefore explores pathways within socialization, utilizing an intensive longitudinal qualitative methodology. This approach allows detailed longitudinal exploration of individual journeys through socialization and specific emergent events that may affect the process. It also allows individual interpretations of and reactions to emergent events to be followed up and tracked over several time points.

To analyse pathways through socialization, we utilize the psychological contract. By focusing on psychological contract‐related events, we aim to contribute knowledge about how psychological contracts unfold and influence adjustment across socialization. Existing research indicates that perceived promises and breach mutually develop during socialization (e.g., De Vos, Buyens, & Schalk, 2003 ) and shape attitudes (e.g., Robinson & Rousseau, 1994 ). However, it is unclear how breach or fulfilment might affect adjustment, because studies have focused on attitudinal outcomes alone, rather than on learning or social integration. Moreover, little is known about the trajectories of individual psychological contracts across socialization. For example, it is possible that breach accumulates over time to an adjustment ‘tipping point’, where the addition of a particular breach on top of a series of previous breaches pushes individuals over a threshold and towards exit. Likewise, instances of fulfilment may accelerate adjustment or reverse a previous negative experience. In investigating these issues, we respond to calls for detailed research examining responses to psychological contract‐related events over time (Rousseau, Hansen, & Tomprou, 2018 ; Tomprou, Rousseau, & Hansen, 2015 ).

In summary, we contribute to the literature by identifying different pathways during socialization and exploring the dynamics of the psychological contract in this process, utilizing a distinctive longitudinal qualitative methodology. Below, an overview of the literature is provided, focusing on non‐linear forms of socialization, the psychological contract during socialization, and theoretical links between the psychological contract and adjustment, leading to the specific research questions to be addressed.

Organizational socialization

There have been several conceptual approaches to the study of socialization. ‘Stage’ models split socialization into temporal phases (e.g., Jablin, 2001 ; Van Maanen, 1976 ), of which ‘encounter’, directly after entry, is considered most important. Other research has examined the antecedents of socialization and adjustment. The ‘tactics’ approach (Van Maanen & Schein, 1979 ) examines the organization's efforts to socialize newcomers, with formal and structured methods being most effective (Jones, 1986 ). Studies of learning show that those who acquire useful information during socialization (Bauer et al ., 2007 ) and undertake proactive behaviours (Saks et al ., 2011 ) report better adjustment.

Research has also examined non‐linear forms of socialization. First, studies have identified some relatively short‐term experiences that impact newcomer adjustment. Examples include conflict with co‐workers (Nifadkar & Bauer, 2016 ), acceptance of newcomers by insiders (Korte & Lin, 2013 ; Moreland & Levine, 2002 ), critical incidents that communicate cultural norms (Gundry & Rousseau, 1994 ), and early support or undermining (Kammeyer‐Mueller, Wanberg, Rubenstein, & Song, 2013 ). Unmet (Wanous, Poland, Premack, & Davis, 1992 ) and misinterpreted (Korte, Brunhaver, & Sheppard, 2015 ) expectations have been shown to hinder adjustment.

Second, newcomers can experience specific periods that are characterized by positive or negative attitudes during socialization. The honeymoon–hangover effect occurs where a job change engenders an uplift in satisfaction that subsequently decreases over time (Boswell, Boudreau, & Tichy, 2005 ). Satisfaction peaks are particularly high for those who learn more during socialization (Boswell, Shipp, Payne, & Culbertson, 2009 ), whilst institutionalized socialization tactics can reduce any decrease in satisfaction that occurs after this peak (Wang, Hom, & Allen, 2017 ).

Third, there has been some examination of discrete critical events that occur during socialization. Louis ( 1980 ) describes ‘surprises’ that occur when newcomers’ overly positive expectations meet with reality, precipitating sensemaking and information seeking. Lee and Mitchell's ( 1994 ) unfolding model of voluntary turnover begins with the occurrence of a ‘shock’ event, which may be perceived as negative or positive and internal or external to organizational life. This triggers a ‘script’ that can result in turnover during socialization (Holtom, Goldberg, Allen, & Clark, 2017 ; Kammeyer‐Mueller, Wanberg, Glomb, & Ahlburg, 2005 ).

In sum, existing literature has identified several factors that affect the socialization process, some indicating non‐linear forms of adjustment. However, research has not explored the nature and range of individual adjustment pathways that occur across socialization, and whilst it recognizes the role of events in shaping adjustment, it has yet to provide detailed insights into the way in which events can shape a dynamic socialization process. Our study seeks to investigate individual pathways across the entirety of the socialization process by addressing the following research question:

Research Question 1 : What are the different pathways that are taken towards more or less successful socialization?

The psychological contract during socialization

If different pathways are identified, this raises questions about their characteristics and what determines them. We examine these questions utilizing psychological contract theory. The psychological contract has been defined as ‘individual beliefs, shaped by the organization, regarding terms of an exchange agreement between the individual and their organization’ (Rousseau, 1995 , p. 9). Several lines of research have examined the role of the psychological contract during socialization.

First, theoretical accounts have highlighted the importance of individual (e.g., information‐seeking behaviour) and organizational (e.g., overarching goals) factors in the development of perceived promises and breach during socialization (Morrison & Robinson, 1997 ; Rousseau, 2001 ; Rousseau et al ., 2018 ; Shore & Tetrick, 1994 ), which lead to transactional or relational psychological contracts (Rousseau, 1990 ). Empirical research confirms that perceptions of promises (Robinson, Kraatz, & Rousseau, 1994 ) and the extent to which they are breached or fulfilled (De Vos & Freese, 2011 ) change across socialization, driven by individual differences, information acquisition, and existing organizational norms (De Vos, 2005 ; Thomas & Anderson, 1998 ).

Second, studies have demonstrated that psychological contract perceptions predict changes in perceived obligations and breach across the first year in the job. For example, employee perceptions of their own contributions and those of the organization positively predict levels of perceived employee and organizational obligations across the first 12 months of service (De Vos et al ., 2003 ; Lee, Liu, Rousseau, Hui, & Chen, 2011 ). Additionally, newcomers perceive lower relational‐based employer obligations across their first 8 months, and consequently perceive greater breach and display poorer attitudes (Tekleab, Orvis, & Taylor, 2013 ).

Third, studies have examined the role of psychological contract perceptions in employee attitudes during socialization. Perceived breach can negatively affect trust, intention to remain, satisfaction, and turnover 2 years post‐entry (Robinson & Rousseau, 1994 ). Organizational commitment mediates the relationship between breach reported by newcomers and turnover intentions measured 4 months later (Lapointe et al ., 2013 ). The attitudes of newcomers who experience breach may take several paths, including remaining below pre‐breach levels or improving beyond them, dependent upon the salience of breach, levels of organizational support (Solinger, Hofmans, Bal, & Jansen, 2016 ), and coping responses (Bankins, 2015 ). Perceived employee obligations around entry can also drive attitudes at 8 weeks (Delobbe, Cooper‐Thomas, & De Hoe, 2016 ). Additionally, psychological contract perceptions act as an intervening mechanism during socialization. Breach mediates the effect of leader–member exchange and perceived support on intention to leave measured at 6 months (Dulac, Coyle‐Shapiro, Henderson, & Wayne, 2008 ), whilst both perceived promises and fulfilment mediate the relationship between learning and attitudes across the first 3 months of tenure (Woodrow & Guest, 2017 ).

Existing literature indicates that the psychological contract, and particularly the formation and delivery of perceived promises, influences attitudes during socialization. However, research has yet to consider the effect of the psychological contract on other aspects of adjustment beyond attitudes. In addition, it remains unclear how the psychological contract unfolds across the entirety of socialization. This is because studies have generally used aggregate‐level quantitative methods, often with short follow‐up periods of 6 months or less (e.g., Delobbe et al ., 2016 ; Dulac et al ., 2008 ), rather than exploring the emergence of breach or fulfilment events and any affects across socialization, for which a 12‐month follow‐up period is considered necessary (Bauer, Morrison, & Callister, 2007 ). Our study therefore addresses these issues.

The psychological contract and adjustment

Existing theory suggests that psychological contract‐related events may be key drivers of adjustment during socialization (e.g., Morrison & Robinson, 1997 ; Rousseau, 2001 ; Rousseau et al ., 2018 ; Shore & Tetrick, 1994 ). At entry, newcomers hold underdeveloped psychological contracts derived from pre‐organizational experience, education, and promises arising from recruitment (Shore & Tetrick, 1994 ). After entry, newcomers absorb information from their environment during their first few weeks and months (Louis, 1980 ) in line with uncertainty reduction theory (Berger & Calabrese, 1975 ), which involves the communication of further promises. Some promises are made explicitly through written or verbal communication, whilst others may be more implicitly encoded via observing others or organizational communications (Rousseau & Greller, 1994 ). The psychological contract that is formed acts as a schema that guides newcomers’ behaviour (Rousseau, 2001 ). This remains relatively stable after the initial weeks and months of work, as a ‘maintenance’ phase is entered (Rousseau et al ., 2018 ), although new promises may continue to be added (Rousseau, 2001 ).

Research suggests that ongoing organizational promise fulfilment facilitates some aspects of adjustment during the first year of tenure, with employees responding with their own contributions (De Vos et al ., 2003 ) via the mechanism of social exchange, reflected in positive attitudes (Zhao, Wayne, Glibkowski, & Bravo, 2007 ). Importantly, it is also likely that some organizational contributions (e.g., training) allow employees to learn about their environment, and some employee contributions (e.g., undertaking specific tasks) involve immersion in organizational life. Consequently, fulfilment could lead to opportunities to build relationships, knowledge about the new environment, and positive work‐related attitudes, indicating adjustment.

Psychological contract breach, where the organization is perceived to have failed to deliver a promise, may derail this process. Breach acts as a ‘disruption’ to the psychological contract, prompting employees to reconsider the terms (Rousseau et al ., 2018 ). Following social exchange, newcomers may remove some contribution after breach, accompanied by negative attitudes towards work (Zhao et al ., 2007 ) and decreasing levels of trust in the organization (Robinson, 1996 ). In serious cases, employees may experience strong feelings of violation, an emotional reaction involving anger and frustration (Morrison & Robinson, 1997 ). The removal of some organizational contributions (e.g., support) may prevent opportunities to learn and socially integrate that are required for adjustment. Breach therefore has the potential to damage the developing employment relationship, leading to negative attitudes and behaviour, poorer social relationships, inhibited learning, and, potentially, turnover.

In sum, consistent fulfilment may lead to better adjustment across socialization, but breach events may disrupt this process. However, these issues are yet to be systematically examined in the literature. Existing studies have focused largely upon how the psychological contract affects newcomer attitudes rather than other aspects of adjustment. Additionally, studies have rarely used detailed exploratory methods that could shed further light on individual experiences during socialization across the first 12 months of tenure. Consequently, it remains unclear how long any effects of fulfilment or breach on adjustment last, whether they may be reversed, and what types and intensities of event are necessary to affect adjustment.

We therefore examine individual accounts of the psychological contract at regular 3‐month intervals across the first year of tenure in an inductive and exploratory fashion. In particular, we address the following research question:

Research Question 2 : How do specific instances of perceived psychological contract breach and fulfilment affect adjustment within pathways through socialization?

Additionally, it is unclear how the timing of significant events during socialization affects adjustment. Robinson and Morrison's ( 2000 ) theory of psychological contract violation development suggests that perceived breach is particularly likely during very early socialization, when uncertain newcomers are vigilant to inconsistencies in the psychological contract and misunderstandings can easily occur between the two parties to the deal, especially if communication is inadequate (Morrison & Robinson, 1997 ). Newcomers are also unlikely to have built supportive relationships at this very early stage, which buffer against the negative effects of breach (Sutton & Griffin, 2004 ). This suggests that breach may be most common and damaging during very early socialization. On the other hand, very early tenure has been described as a time of promise negotiation (e.g., Shore & Tetrick, 1994 ), when the psychological contracts of inexperienced newcomers may more easily cope with deviations in the employment relationship compared to experienced staff whose psychological contracts have been formed over a longer period (Rousseau, 2001 ). This suggests that breach may be less harmful at an early stage of tenure. Since theory in this area is mixed, we explore the role of timing in the outcomes of breach and fulfilment by answering the following research question:

Research Question 3 : Does the experience of breach and fulfilment, and any effect on adjustment within pathways, differ depending on when it occurs during the socialization process?

The research, conducted in a large hospital in London (UK), adopted a longitudinal qualitative design. The study used repeated interviews, including critical incidents (Flanagan, 1954 ). This type of phenomena‐based case study provides a more suitable method to assess our exploratory research questions and build theory (Eisenhardt & Graebner, 2007 ) compared with more intensive methods such as diary studies. This approach also allowed the investigation of the experience of breach and fulfilment over time, enabling participants to reflect upon the same event at different points.

Newcomers to the organization were invited to participate in the study during 8 weekly ‘sign‐in’ days, where they reported to HR on their first day of work. Those who were happy to participate undertook an initial interview. Up to five interviews were conducted with each participant across the study, at entry, 3, 6, 9, and 12 months. Twelve months has been used as acceptable follow‐up period to capture the important aspects of socialization (De Vos & Freese, 2011 ). The remaining interviews were evenly spaced at 3‐month intervals to examine the evolving socialization process. This follow‐up schedule is considered appropriate for capturing the meaningful aspects of socialization (Bauer et al ., 2007 ; De Vos et al ., 2003 ).

Participant characteristics

Forty‐one individuals undertook an initial interview at day 1. Of these, nine could not be contacted again, four were current employees of the organization, and one was joining on a short‐term contract, leaving a usable sample of 27 participants who undertook 112 interviews. Eight participants voluntarily left the organization during the study period. Participants were a mix of occupational groups broadly in line with that of the workforce as a whole, including nurses, other health professionals, and administration staff. Six participants were entering their first job in their profession. The mean age of participants was 31 years, 71% were female, and 38% were from Black, Asian, and Minority Ethnic backgrounds.

Each interview lasted up to 40 min. The day 1 interview was used to collect demographic data and examine perceived psychological contract‐related promises and commitments that the organization had made. Each subsequent interview began with a series of questions examining perceived learning, attitudes, social integration, supervisory, and other support. Psychological contract breach and fulfilment were assessed in two ways. A critical incident technique (Flanagan, 1954 ) was used, with participants asked to recount any incidents that related to negative or positive events at work. These were probed if they reflected perceived breach or fulfilment. Additionally, participants were asked about the extent to which managers were perceived to have kept or broken any promises or obligations, and whether they felt they had been treated fairly, with emergent issues probed. Participants were also asked about the status of any perceived breach and fulfilment described in previous rounds.

NVivo software was used to organize transcripts and record coding. Analysis began with thematic coding of individual interviews using the approach of Miles and Huberman ( 1994 ). At stage 1, data were coded specifically for instances of perceived breach, fulfilment, organizational promises, adjustment, and attitudes. For the purposes of analysis, ‘perceived promises’ were coded where employees believed that their organization had promised or was obliged to provide a particular contribution in the future, in line with common conceptualizations (e.g., Coyle‐Shapiro & Kessler, 2002 ; Rousseau, 1990 ). Perceived breach was defined as ‘the employee's perception regarding the extent to which the organization has failed to fulfil its promises or obligations’ (Zhao et al ., 2007 , p. 649). Perceived fulfilment was coded where participants demonstrated the cognition that their organization had fulfilled promises or obligations. Codes relating to adjustment were applied where participants discussed learning about the role, team, and organization that enabled effective job performance (Haueter et al ., 2003 ), the development of positive work‐related attitudes (Saks & Ashforth, 1997 ), and positive relationships with insiders (e.g., Moreland & Levine, 1982 ; Ostroff & Kozlowski, 1992 ). A broad view of learning was used which included aspects of social integration and acceptance, in line with previous conceptualizations (e.g., Ostroff & Kozlowski, 1992 ).

At stage 2, exploratory open coding was applied to the entire data set to build upon preliminary codes and develop new ones. This initial coding process led to the development and refinement of lower level codes, which were grouped into pattern codes (e.g., ‘perceived causes of breach’, ‘perceived consequences of fulfilment’, ‘job learning’). At this stage, a set of perceived types of breach and fulfilment experienced by study participants was extracted from the data (see Table  1 ). A sample of approximately 20% of transcripts were independently examined for critical events by two coders. There was minor disagreement on a small number of events, which was resolved by discussion and used to inform ongoing coding.

Breach and fulfilment experienced by study participants

Terms in brackets denote abbreviations used in Tables ​ Tables2 2 and ​ and4 4 .

At stage 3, data were analysed on a longitudinal basis using the systematic approach of Saldaña ( 2003 ), which involves examining data using three sets of analytical questions. ‘Framing’ questions are used throughout the coding process and identify changes over time (e.g., Which differences occur between data collection points; when do these occur?); ‘Descriptive’ questions act as a bridge between framing and interpretation (e.g., what increases or is cumulative across time; do ‘surges’ or ‘epiphanies’ occur?); ‘Analytic/interpretive’ questions are then used to interpret the changes identified earlier (e.g., are there interrelationships between changes?).

Interviews were first analysed on a within‐participant, case‐by‐case basis, in conjunction with codes developed earlier. At this stage, various changes over time were coded (e.g., ‘breach of salient promise followed by intention to exit’; ‘over‐fulfilment followed by learning about role’), each with associated codes from stages 1 and 2 (e.g., ‘social integration’; ‘learning’; ‘support’). Between‐participant analysis was then undertaken. This resulted in the emergence of five overarching themes concerning distinct pathways through socialization (e.g., ‘Gradual adjustment through promise fulfilment’; ‘Accelerated adjustment through over‐fulfilment’), each underpinned by a set of codes relating to aspects of the employment relationship (e.g., ‘breach salience’; ‘management support’). Analysis was aided by the use of Miles and Huberman's ( 1994 ) time‐ordered matrices, detailing each participant's journey using one entry for each time point. Table  2 shows the matrix for perceived breach events.

Time‐ordered matrix for emergent breaches by follow‐up

Types of breach and fulfilment

Initial analysis of the entire data set identified nine distinct types of promise that were breached or fulfilled during the study (shown in Table  1 ). Some related to promises that had emerged at the initial interview, whilst others had subsequently become part of the psychological contract. Promises were derived from a variety of sources, but the agent of delivery (Rousseau, 1995 ) was in almost every case viewed as being a direct supervisor or a departmental supervisor with specific responsibility for training, who was often not the source of the initial promise. Some participants (such as those described in pathway 4) altered their attribution of responsibility for breach from hospital management in general to their direct manager as the study progressed.

Instances of fulfilment relating to specific promises emerged less often than instances of breach, because participants often described fulfilment in more general terms. For example, Participant 19 stated that ‘I can't think of anything that … they've promised and it's not been delivered’. Most commonly reported instances of breach across all rounds and participants related to Training (12) and Support Structure (15). A greater proportion of study participants (20 of 27) reported breach at 3 months compared to 12 months (2 of 19). Most participants did not report new instances of breach or fulfilment at every follow‐up, and three individuals did not report any breach during the study.

Initial psychological contracts

The initial interviews focused upon perceived promises made at entry. The following types of promise were reported at this stage: Support Structure ; Training ; Workload; and Quality of Care . In line with Rousseau ( 1995 ), promises originated via both human (e.g., conversations with insiders during recruitment, including but not limited to managers) and structural (e.g., organizational literature) sources. Some were more implicit, such as the provision of particular types of training that were described in literature but never formally promised. Others, such as the provision of a mentor, were promised explicitly during recruitment. Initial interviews were conducted prior to individuals having started their jobs, and many stated that they expected to learn more about what the organization would provide during their formal induction and initial weeks in post.

Many participants discussed adjustment in terms of the development of a strong network in their work area and generally positive attitudes towards their work. Less experienced newcomers, particularly those entering their first job in their profession, described developing an understanding of their role as an important part of adjustment. For more experienced newcomers entering from similar jobs elsewhere, the role itself was far less important. An experienced midwife illustrates this:

I know the midwife area is always busy….midwifery is midwifery, no matter where you find yourself. [Participant 33]

Several saw their ability to integrate through proactive behaviour as a major achievement. Newcomers highlighted the importance of social integration into their work area, rather than into the organization as a whole:

I guess, if anything, I feel more part of this building and the ethos of the building…I don't feel like I am part of the hospital staff. [Participant 16]

Pathways of breach and fulfilment through socialization

Longitudinal analysis of the data set led to the emergence of five distinct psychological contract pathways through socialization, each exhibiting distinct temporal characteristics. Additionally, three themes emerged that cut across the pathways, relating to manager support, organizational responsiveness, and the type of promise made. These pathways are represented graphically in Table  3 and explained below. Table  4 summarizes the critical psychological contract events reported for each pathway.

Six psychological contract pathways through socialization

Summary of psychological contract events reported for each socialization pathway

T1 = 3 months; T2 = 6 months; T3 = 9 months.

Pathway 1: Gradual adjustment through promise fulfilment

The first emergent pathway involved individuals for whom adjustment happened gradually and reasonably smoothly, with participants reporting that promises had generally been fulfilled throughout. This was the most common pathway and included 13 study participants (around half the sample).

Most participants, and particularly those more experienced in their profession, viewed promise delivery with a sense of ambivalence. When asked about the delivery of promises and obligations, statements such as ‘I can't complain’ [Participant 34] were common. Hence, in many cases, fulfilment acted via the removal of potential barriers to adjustment. Some participants described the fulfilment of promises, such as provision of training that had been discussed at interview or described in a job advertisement. Others stated that little explicit promise‐making had taken place. For some less experienced participants, fulfilled promises contributed to adjustment by making contributions (e.g., training or enlarged job content) that enabled them to learn the important aspects of their new environment and develop social relationships. Participant 5, a nurse, was made promises regarding training and support. Delivery of these promises helped her to integrate socially, and to learn about her role and pass a test necessary to administer drugs:

I passed first time…other colleagues who'd already done the test were very supportive. My practice development nurse is very supportive….it is something you will have had to have passed before you can administer drugs.

Most participants in this pathway reported broadly positive attitudes throughout, demonstrating adjustment after 6 or 9 months. Accounts were characterized by strong support from their direct managers who responded to minor instances of breach. Many reported that some promises had not initially been fulfilled. However, these often related to issues that were not of particular importance to the individual and were swiftly righted by the organization. For example, Participant 23, an allied health professional, stated at 3 months that a promised supervisory structure was not in place:

When I first started, they weren't really sure who even my supervisor was going to be, and I think those processes took some time. I didn't have an appraisal until two months into my first job.

However, at later follow‐ups, she reported that this situation had little effect on her attitudes, since it was not of particular importance to her:

I've got a new supervisor now… absolutely fine, no problem at all now. [I am] really integrated … I suppose it takes a few months to settle in and feel like ‘okay, now I am part of the team’.

Pathway 2: Accelerated adjustment through over‐fulfilment

The second pathway that emerged concerned cases where fulfilment acted as an event that led to a sharp upturn in adjustment. The defining characteristic of these cases was the presence of over‐fulfilment, where perceived promises were delivered above the expected level.

This type of turning point was experienced by two individuals. In each case, it was reported at 3 months and concerned the provision of training. This experience was viewed as an act of goodwill towards newcomers that increased trust in the organization and enabled them to quickly build social networks and learn about their environment, setting the course for a positive journey through socialization. Subsequently, each participant adjusted quickly to their role, reported a general happiness with most aspects their work at each additional follow‐up, and remained with the organization at 12 months.

Participant 18, a non‐clinical support employee, reported at the 3‐month follow‐up that she had been provided with training over and above what had been promised:

A lot more… it's just the training I've received …I've never done dental before, but I've received quite a lot of support….I'm extremely happy.

At the 6‐ and 9‐month interviews, she felt fully adjusted and reported that promises were still being met:

I was very positive and I still am. Things are getting even better and better…I get quite a lot of support, which is excellent….I've been very lucky that in my case they've kept [their promises], especially with the training and the support…I got it all. I have integrated really well… in terms of my job and the other departments.

Participant 6, a nurse, stated at the initial interview that she had been promised ‘training and….in the first months, I will be very well supported’. At 3 months, she revealed that this training had been above the promised level:

Better than I thought it would be. I had more support than I thought I would have…they had somebody to work with me for my first few shifts …it is nice to have somebody just to show you how they do things.

At subsequent interviews, she continued to report positive attitudes, strong line manager support, good knowledge of her environment, fulfilled promises, and positive relationships. At 12 months, she reported feeling adjusted and socially integrated, particularly within her immediate work area:

I think [I am integrated] more in my job on the unit than at [the hospital] as a whole. …I feel I'm integrated enough at [the hospital] so it's fine.

Pathway 3: Positive turning point through fulfilment

The third emergent pathway was characterized by a negative experience that, through organizational action, later became positive and led to adjustment. The two individuals in this pathway experienced the breach of a salient promise. However, at subsequent interviews they revealed that the organization had fulfilled this promise, which led to a reversal of their negative attitudes and perceptions of adjustment.

The initial breach in these cases was reported at 3 months, with subsequent organizational action to remedy it reported at 6 or 9 months. One breach related to a promised support structure and one to promised training. Line manager support and organizational responsiveness were intertwined and of critical importance to this pathway, since a change of supervisor led to delivery of a perceived promise that the previous supervisor had failed to deliver in both cases. The effect of promise delivery provided an uplift in attitudes and allowed participants to learn more about their environment and build networks via the actual contribution offered, resulting in better adjustment.

Participant 33, an experienced midwife, stated at entry that she joined the organization in order to undertake a particular training course that was described in messages from the organization. At 3 months, she reported beginning to settle into the role, aided by previous experience. However, she reported a breach when a supervisor stated that it was not possible to undertake the training after all, leading to relationship difficulties with the supervisor and inhibiting learning. At this stage, the participant considered leaving:

I spoke to [the supervisor] about a course that I wanted to do… she said there's no place for me…it's one of my main reasons for coming….I am thinking about whether to stay here and continue to wait for me to do the course or to try somewhere else.

At 9 months, the situation changed. Her supervisor had been replaced by an individual who found her a training place:

[The supervisor] has been away for some time now, and somebody else is doing her job… [they will] help me go on the course….I don't think I have any problems as far as work is concerned.

The delivery of this promise, coupled with the change in supervisor, triggered far more positive attitudes about the environment and team:

I've been there for about nine months now at least, I've become used to the routines of the hospital, familiar with the hospital policies, so I feel much at home …they've all been nice, the managers and my colleagues have been nice.

Finally, at 12 months, she reported feeling fully adjusted and integrated, having seen a change in the way the department operated since joining:

When I first started the newcomers were isolated, but I've really seen a change…the initial welcome was not the best….but things have really improved.

Pathway 4: Cumulative breach to tipping point

The fourth pathway involved a negative turning point in the form of a psychological contract breach. We classify this as a ‘tipping point’, whereby one particular breach following a series of breaches pushed individuals over a threshold, leading to exit.

Two individuals in the data set were coded under this pathway. In each case, a number of breaches were experienced until, finally, the newcomers decided that they no longer wished to remain in the organization. One individual left for another job between 6 and 9 months of service. The second was searching for a new post at the 12‐month interview. Adjustment was stunted throughout, because breaches denied access to aspects of organizational life that would promote learning and social adjustment, causing frustration and impaired trust in management. Both instances of tipping points occurred during the later phases of the study, at 6 and 9 months, relating to ‘quality of care’ and ‘pay and advancement’. These pathways were characterized by perceptions of poor line manager support, a large number of breaches during socialization, and a lack of organizational resolution of these breaches.

Participant 7, a trainee allied health professional, experienced a difficult time during his first year of work. At 3 months, he learnt that there was a recruitment freeze and his department was likely to close, and reported breaches relating to understaffing and support. Despite some setbacks, he reported beginning to adjust through learning about his new organization and displayed generally positive attitudes:

It's going alright….they've given me training and made sure that I'm alright…the biggest achievement really is being able to integrate myself into all the departments.

At 6 months, these breaches had not been resolved, and a further breach emerged relating to removal of training opportunities. The final straw for this participant, however, was revealed at the 9‐month interview, concerning a promised salary increment that had been reneged upon:

You are supposed to get a pay increase after six months, and we were promised to get this, and then all of a sudden they turned around and said: ‘you can't have it unless you do this [training] program’.

This was one broken promise too many, and he began searching for another job, continuing at the 12‐month interview. At this point, he stated that whilst he felt somewhat socially integrated at the team level, he had a poor relationship with his supervisor and the breaches relating to training had prevented adjustment into the role:

Everyone is friendly with literally everyone at work…I am friends with everyone except my line manager…[but] I haven't officially learned anything, because I haven't been able to go on any training courses. CV wise, I haven't actually had any advances.

This participant attributed the breaches at 3 months to organizational‐wide issues rather than to his own manager, describing them as ‘a bit unfair, but…unfortunately a necessary evil’. The later breaches, by contrast, were attributed to his direct manager: ‘I'm not sure it's so much saving money; I think that was more of a way to try and get to us a little bit’.

Pathway 5: Negative turning point through violation

The final pathway that emerged from the data also involved a negative turning point in the form of a psychological contract breach. Here, four participants who were experiencing an otherwise broadly positive socialization experience were jarred towards poor levels of adjustment by the perceived breach of a particularly salient promise. In each case, the breach led to job search behaviour. In two of these cases, the individuals left the organization for another job before 12 months of service. Breaches of this type elicited strong feelings of anger, frustration, or betrayal, characteristic of high levels of psychological contract violation (Morrison & Robinson, 1997 ). This type of critical turning point event was reported at varying follow‐up points: at 3 months, at 6 months, and twice at 9 months. The types of promise to which breaches pertained also varied. Two related to supervision and two to access to annual leave. The critical issue in these cases was the importance of the promise to the individual.

Participant 4, a trainee health professional, was assured at entry that she would be able to take a holiday at a particular time. During the early interviews, minor breaches were reported, relating to inadequate staffing, time off, and access to training. She continued to adjust, although she reported a poor relationship with her manager, stating at 6 months that she had learnt about her new environment and role: ‘I feel completely a part of the hospital because the people who work here are amazing…except my manager’; and that ‘nothing is perfect, but for now…I'd say I'm happy’. However, at 9 months, she reported that the promise to take holiday had been reneged upon by her manager. This elicited a strong negative reaction and, consequently, she reported that her positive attitudes towards the hospital were reversed and began searching for a new job:

When they hired me…they said ‘no problem’. Now because they are doing cuts they've come to us and said ‘now you can't’. For me that is definitely not acceptable… So I already told my boss that if I find something else …I will leave.

If they start making rules when only one can go on holiday it's wrong, which was not part of the deal when they hired me! Those things don't make me feel so connected to [the hospital].

Participant 26, a patient‐facing administrator, experienced a similar journey. At 3 months, she stated that she was integrating well into her team and being given time by her mentor to learn the ropes:

[My mentor has] done it in stages with me, which is really, really helpful…she's given me the time to understand what I need to understand. And as I grasp it we move onto another part.

However, at 6 months, she reported two breaches which led her to begin searching for a new job. One related to management's failure to protect her from patient abuse and the other to the removal of a promise that staff could leave their shift once cover is in place:

The nurses, once they've done their handover, even if it's five past eight, they can actually leave once their cover has come in. And our line manager said the same thing. Well, once confronted by their manager, they've backed down. For me, I just think it's just so wrong.

These incidents were viewed as a serious betrayal, leading to anger and a poor relationship with her managers, and prompting her to state that ‘I'm not going to stay. That's not the sort of environment I can work in’. At the 9‐month follow‐up, she had left for another job.

The pathway was characterized by a departmental management structure that was perceived to be poor and unsupportive. Participants described a lack of responsiveness to complaints about breach, with attempts to discuss issues with managers often ignored. Individuals described feeling somewhat adjusted, having worked hard to build networks and learn about their environment, despite negative relationships with management. However, the breaking of a particularly salient promise derailed these efforts, setting them on a path to exit.

We present research designed to advance the literature on organizational socialization by addressing three interrelated issues that have remained unresolved. Because of the exploratory nature of our research questions, we undertook a longitudinal qualitative study using critical incidents of psychological contract breach and fulfilment to examine how newcomers interpret their experiences, and any specific events that occur, across the entirety of socialization.

Our first research question asked whether it is possible to identify pathways through the socialization process. Analysis led to the identification of five distinct pathways. The second research question addressed the role of psychological contract breach and fulfilment as a means of understanding and explaining adjustment within pathways. Analysis reveals that each of the five pathways was defined by psychological contract‐related characteristics. One pathway shows that many experience gradual adjustment, with promises generally fulfilled. Another reveals that exceeded promises can provide a positive turning point, accelerating adjustment. A third provides evidence that after breaches have occurred, subsequent fulfilment of salient promises can act as a positive turning point. A fourth reveals that newcomers can reach a ‘tipping point’ after a series of breaches, and a fifth shows that breach acts as a negative turning point where it involves violation of a salient promise. Our third research question concerned the timing of relevant events during socialization. Analysis confirms that events had a profound effect on the success of socialization at any time over the 12 months of our study, although some trends linked to particular pathways emerged. Over‐fulfilment that led to very rapid adjustment occurred in early socialization. Fulfilment of a previously breached promise that led to an upturn in adjustment occurred later in the process. ‘Tipping points’ that occurred after a series of previous breaches also occurred later in the process.

Theoretical implications

Our findings demonstrate that psychological contract breach and fulfilment act as discrete ‘turning point’ events across the entirety of socialization, influencing adjustment and helping to determine the pathway that is taken through socialization. Whilst research has shown that socialization does not proceed linearly (e.g., Boswell et al ., 2005 ), we add to the literature describing potential ‘issues’ (e.g., Korte et al ., 2015 ) or ‘shocks’ (e.g., Holtom et al ., 2017 ) that may occur. Socialization has been characterized as a process of overcoming challenging hurdles (e.g., Ashforth et al ., 2007 ) that leads to sensemaking (Louis, 1980 ) and adjustment. This research shows that perceived breach and fulfilment of the psychological contract precipitate rapid adjustment as well as disengagement, such that many who go on to become socialized have experienced events with negative and positive outcomes. The psychological contract has often been positioned as an outcome of socialization (e.g., De Vos & Freese, 2011 ) or a driver of attitudes (Robinson & Rousseau, 1994 ). We show that it is important for all aspects of adjustment. Importantly, adjustment often hinged upon one particular aspect of the job, such as a training place. Hence, individuals who reported making efforts to integrate and build networks were still jarred towards poor adjustment (and possibly exit) when denied something of particular importance.

The findings of this study demonstrate that the function of breach and fulfilment may differ by stage. During early socialization, in what is often called the encounter phase, over‐fulfilment spurred employees into early adjustment by providing the tools to socially integrate and learn the job, facilitating positive attitudes. Fulfilment later in socialization sometimes served as corrective action to restore trust and aid adjustment that had been harmed by previous negative experiences. Breach that occurred late in socialization, particularly if following earlier breach, tipped some participants towards exit. Serious breach that resulted in strong feelings of violation acted primarily by impairing attitudes and trust in the organization, acting as turning points at any stage. Additionally, participants’ levels of previous experience influenced the importance of features of adjustment. Newcomers with limited experience in their profession were particularly concerned with role‐related aspects of adjustment, whereas experienced newcomers were more concerned with social integration, adding to previous findings that more uncertain inexperienced newcomers benefit more from the use of ‘institutionalized’ socialization tactics (Saks et al ., 2007 ).

Our findings also provide several theoretical implications regarding the ‘unfolding’ nature of particular promises and their fulfilment or breach, an area that has received limited prior attention (e.g., Conway & Briner, 2005 ; Rousseau et al ., 2018 ). First, previous theoretical work suggests that the effect of perceived breach can depend upon the importance of the breached promise (Morrison & Robinson, 1997 ; Schalk & Roe, 2007 ). We provide empirical evidence that perceived breach of particularly important promises affects adjustment. Second, previous cross‐sectional research has demonstrated that the effect of perceived breach on attitudes is not linear but becomes stronger when a certain intensity of breach is perceived (Rigotti, 2009 ). We add to these findings by showing that individual instances of breach may be additive over time in terms of their effects on all aspects of newcomer adjustment. Third, Tomprou et al . ( 2015 ) discuss the importance of perceived organizational responsiveness in repairing broken promises, and empirical evidence demonstrates that post‐breach support can enhance recovery with respect to commitment (Solinger et al ., 2016 ). This analysis demonstrates that fulfilment of a previously breached promise may provide a positive turning point. Finally, previous research shows that over‐fulfilment may have a positive impact, albeit to a lesser degree than the negative impact of under‐fulfilment (Conway & Briner, 2002 ), and may lead to a positive renegotiation of the deal (Rousseau et al ., 2018 ). Our research shows that in very early tenure, where organizational contributions refer to an issue that can aid learning about the environment, over‐fulfilment may have a very strong positive impact upon adjustment.

Practical implications

This research has implications for the management of newcomers during socialization. First, the research implies that the management of broken promises is particularly important, because a series of unresolved breaches, even if seemingly unimportant when viewed individually, can inhibit adjustment and precipitate exit. Second, the research shows that damage done by broken promises may be undone through subsequent fulfilment. This suggests that where individual promises are broken, managers should not forget about them, since employees are unlikely to. Rather, managers should seek to explain why the promise was broken and try to fulfil it later. Our findings highlight the important role of the supervisor and the support they provide, since instances emerged where fulfilment of a previously breached promise was delivered by a newly appointed and more supportive manager. This points to a case for training supervisors in management of newcomers, sensitizing them to many of the points raised including the importance of managing the psychological contract.

Third, our research shows that delivery (or over‐delivery) of perceived promises concerning important learning opportunities during very early socialization can have strong and lasting effects upon adjustment, whilst other promises were viewed as less significant even when broken. This suggests that managers might prioritize particular types of contribution during early tenure, whilst being aware of relevant previous experience of newcomers. Finally, perceived promises may arise from a variety of sources during recruitment, of which managers in departments may be unaware. It is therefore important only to make promises that can realistically be kept, and for managers to be made aware of the perceived promises that newcomers may hold.

Limitations and future research

Our study was conducted with a fairly small number of staff in one context. Whilst our aim was to elicit rich information about socialization, it is not clear whether the five pathways identified here are found in other contexts. Furthermore, three pathways each contained only two participants. Further research can confirm these or other potential pathways. Additionally, we only assessed the perceptions of newcomers, when the perceptions of organizational insiders who may play a role in both adjustment (Moreland & Levine, 1982 ) and the psychological contract (Guest, 1998 ) could provide an additional perspective.

Aspects of the emergent findings could be investigated further with longitudinal qualitative or possibly quantitative methods. One concerns the accumulation of psychological contract breach, where a particularly important question relates to how much breach individuals can take, over time, before they reach a tipping point. Second, the findings concerning subsequent fulfilment of a previous breach are novel. Future research might explore factors that facilitate this, such as the influence of a change of manager which was important here. Third, this research shows that the type of promise is important, and this issue may be usefully investigated in other contexts with more participants. Fourth, our study took place in a large hospital which may help to explain a gap between promises made during recruitment and some of the challenges of ‘local’ socialization, as well as the limited interest in integration into the organization as a whole. Future research in smaller organizations may present a different picture. Finally, our research highlights the general utility of adopting relatively novel methods to explore and build on theory, and specifically the use of longitudinal qualitative research to analyse the time domain in the evolution of the psychological contract and socialization.

Our research advances knowledge about organizational socialization and the psychological contract in several ways. First, it has drawn attention to the variety of pathways in socialization. Second, it has demonstrated the value of the psychological contract in understanding the evolution of the socialization process, revealing that whilst it can be a smooth process, instances of fulfilment and breach can lead to turning points and tipping points. Longitudinal qualitative methodology advances our understanding of the dynamic state of the psychological contract during periods of instability such as socialization by using the critical incident technique to demonstrate how specific events affecting fulfilment or breach can alter the trajectory of organizational socialization. Rather than representing an outcome of socialization, the psychological contract can have a large influence on whether adjustment occurs at all.

Acknowledgements

This paper presents independent research commissioned by the National Institute for Health Research (NIHR). The views expressed in this paper are those of the author(s) and not necessarily those of the NHS, NIHR or the Department of Health. Funding for the research was provided by the NIHR.

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Organizational socialization.

• Brenda L. Berkelaar Brenda L. Berkelaar Department of Mathematics and Industrial Engineering, Polytechnique Montréal, Université de Montréal
•  and  Millie A. Harrison Millie A. Harrison Department of Communication Studies, The University of Texas at Austin
• https://doi.org/10.1093/acrefore/9780190228613.013.127
• Published online: 23 May 2019

Organizational socialization is the process by which people learn about, adjust to, and change the knowledge, skills, attitudes, expectations, and behaviors needed for a new or changing organizational role. Thus, organizational socialization focuses on organizational membership, which includes how people move from being outsiders to being insiders and how people move between organizational roles within and across organizations over time. To date, research has focused on how employment organizations encourage newcomers to align with existing role expectations via tactics that encourage assimilation . However, organizational socialization is a dynamic process of mutual influence. Individuals can also influence and shape the organization to align with their desires, via personalization tactics. Thus, organizational socialization describes the process by which an individual assumes a new or changing role in ways that meet organizational and individual needs.

Most research on organizational socialization focuses on how newcomers enter paid work environments. Researchers often focus on the tactics organizations use to encourage people to assimilate into the organization during the early or entry stage. Less attention has been given to the later stages of organizational socialization (active participation, maintenance, exit, and disengagement), non-work organizations, and transitions between roles within an organization. However, a growing body of research is considering organizational socialization into volunteer roles, new or changing roles, and later stages of socialization such as exit and disengagement. Scholars and practitioners also increasingly recognize how individual, organizational, contextual, and technological factors (e.g., socioeconomic status, race, gender, new information and communication technologies, time, and boundaries) may alter how organizational socialization works and with what effects—thereby offering insight into the underlying processes implicated in organizational socialization. Future areas of research related to context, time, boundaries, communication, and the ethics of organizational socialization are highlighted.

• organizational socialization
• individualization
• assimilation
• learning processes
• organizational adjustment
• organizational behavior
• acculturation
• organizational membership

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The Oxford Handbook of Organizational Socialization

Connie Wanberg, Ph.D., is the Industrial Relations Faculty Excellence Chair and Associate Dean of Undergraduate Programs at the Carlson School of Management at the University of Minnesota.

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Organizational socialization is the process by which a new employee learns to adapt to an organizational culture. This crucial early period has been shown to have an influence on eventual job satisfaction, commitment, innovation, and cooperation, and ultimately the performance of the organization. After decades of research on organizational socialization, much is now known about this important process. However, some confusion still exists regarding what it means to be socialized. The Oxford Handbook of Organizational Socialization brings reviews of the scholarly literature together with perspectives on what is being done in organizations to integrate and support new employees. The first section introduces the principles and practice of employee socialization and provides a history of the field, and the second section focuses on outcomes and antecedents of socialization. The third section on organizational context, systems, and tactics covers an extensive number of topics, including diversity, person-organization fit, and social networks, and special contexts such as socialization into higher-level jobs, and expatriation. The fourth section reviews process, methods, and measurement. The fifth section goes &#x201;beyond the organizational newcomer&#x201D; to examine socialization in special contexts. The sixth section expands on practice-related issues and walks the reader through two case studies, one in an academic setting and another in a corporate setting. The final articles provide a &#x201C;best practices&#x201D; approach, based on the highest quality research, summarize the state of the field, and offer an agenda for future research as well as suggestions for potential research-practice partnerships.

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Organizational Socialization: Background, Basics, and a Blueprint for Adjustment at Work

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Please note you do not have access to teaching notes, how newcomers use role models in organizational socialization.

Journal of Workplace Learning

ISSN : 1366-5626

Article publication date: 1 October 2004

This study examines how newcomers use colleagues as role models in organizational socialization, taking a multiple level approach to organizational socialization as individual, social and cultural learning processes. The newcomers' most important personal characteristics are expectations, experience, self‐confidence and competitive instinct. These personal characteristics were affected by early experience during the first four to six weeks in their new job. The study shows not only the correlation between early experience and personal characteristics, but also reveals a strong correlation between early experience and organizational socialization outcome. Newcomers rely on role models, and as a result of interaction and observation they acquire different qualifications from several role models. The term “multiple contingent role models” is introduced to explain how newcomers use role models.

• Learning processes
• Workplace learning
• Socialization
• Organizational culture
• Employee development
• Peer mentoring

Filstad, C. (2004), "How newcomers use role models in organizational socialization", Journal of Workplace Learning , Vol. 16 No. 7, pp. 396-409. https://doi.org/10.1108/13665620410558297

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Socialization at Universities: A Case Study

2022, European Journal of Educational Sciences

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Several roads lead to international norms, but few via international socialization: a case study of the european commission.

Published online by Cambridge University Press:  18 October 2005

Can an international organization socialize those who work within it? The European Commission of the European Union is a crucial case because it is an autonomous international organization with a vocation to defend supranational norms. If this body cannot socialize its members, which international organization can? I develop theoretical expectations about how time, organizational structure, alternative processes of preference formation, and national socialization affect international socialization. To test these expectations for the European Commission, I use two surveys of top permanent Commission officials, conducted in 1996 and 2002. The analysis shows that support for supranational norms is relatively high, but that this is more because of national socialization than socialization in the Commission. National norms, originating in prior experiences in national ministries, loyalty to national political parties, or experience with one's country's organization of authority, decisively shape top officials' views on supranational norms. There are, then, several roads to international norms. For comments and advice, I am grateful to Jeffrey Checkel, Gary Marks, Donald Searing, and the editors and two anonymous reviewers for International Organization . An earlier draft was presented at the Center for European Studies of the University of North Carolina at Chapel Hill. This project received funding from the Center for European Studies, University of North Carolina at Chapel Hill, and from two grants by the Canadian Social Sciences and Humanities Research Council (1996–99, 1999–2002). Gina Cosentino, Erica Edwards, Michael Harvey, and Moira Nelson provided research assistance.

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• Volume 59, Issue 4
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• DOI: https://doi.org/10.1017/S0020818305050307

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The path of rural social capital improvement in china from the perspective of planners: a case study of hongtang village in yunnan province.

1. Introduction

2. literature review, 2.1. transformation of development paths in china’s rural areas, 2.2. the significance of rural social capital, 2.3. the construction strategy of rural social capital, 2.4. rural participatory planning for social capital, 3. theoretical framework, 3.1. a social–spatial analysis perspective, 3.2. framework of improving social capital through rural planning, 4. an empirical practice in hongtang village, china, 4.1. introduction of hongtang village, 4.2. the upgrade process of small vegetable garden, 4.2.1. from “intervene” to “motivate” (november 2021 to may 2022): the construction of a demonstration site to drive the surrounding villagers, 4.2.2. from “motivate” to “enable”(june 2022–august 2022): coordinated use of surrounding resources under the guidance of planners, 4.2.3. from “enable” to “empower” (after september 2022): villagers independently mobilize surrounding resources for upgrade, 5. discussion, 5.1. social capital improved through rural planning, 5.2. social relations and knowledge interaction among multiple subjects, 6. conclusions, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Hou, X.; Chen, L.; Huang, Y.; Long, Y.; Li, X. The Path of Rural Social Capital Improvement in China from the Perspective of Planners: A Case Study of Hongtang Village in Yunnan Province. Land 2024 , 13 , 1106. https://doi.org/10.3390/land13071106

Hou X, Chen L, Huang Y, Long Y, Li X. The Path of Rural Social Capital Improvement in China from the Perspective of Planners: A Case Study of Hongtang Village in Yunnan Province. Land . 2024; 13(7):1106. https://doi.org/10.3390/land13071106

Hou, Xianyu, Luan Chen, Yaofu Huang, Ye Long, and Xun Li. 2024. "The Path of Rural Social Capital Improvement in China from the Perspective of Planners: A Case Study of Hongtang Village in Yunnan Province" Land 13, no. 7: 1106. https://doi.org/10.3390/land13071106

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• Introduction
• Conclusions
• Article Information

CPSS indicates Chronic Pain Self-Efficacy scale (to measure pain self-management); PEPPI, Perceived Efficacy in Patient-Physician Interactions scale (to measure self-efficacy for communicating with physicians about patient-reported pain); SBQ, Shortened Barriers Questionnaire (to measure pain misconceptions).

P values are as follows: A, P  < .001; B, P  < .05; C, P  < .001; D, P  < .001. Error bars indicate SDs.

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Shen MJ , Stokes T , Yarborough S , Harrison J. Improving Pain Self-Management Among Rural Older Adults With Cancer. JAMA Netw Open. 2024;7(7):e2421298. doi:10.1001/jamanetworkopen.2024.21298

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Improving Pain Self-Management Among Rural Older Adults With Cancer

• 1 Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington
• 2 Maury Regional Medical Center, Columbia, Tennessee
• 3 Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island

Question   Is the adapted version of Cancer Health Empowerment for Living without Pain (CA-HELP) feasible, acceptable, and able to improve pain outcomes among older adults with cancer living in rural settings?

Findings   Study findings from this case series design study of 30 patients suggested the adapted version of CA-HELP was feasible, acceptable, and able to improve patients’ communication about their pain to their clinicians.

Meaning   Study results highlight a potentially low-cost, low-burden intervention designed to improve pain communication and reduce pain severity and pain misconceptions among older adults with cancer in rural settings.

Importance   Undertreated cancer pain is a major public health concern among older adults in rural communities. Interventions to improve pain management among this vulnerable population are needed.

Objective   To test the feasibility, acceptability, and changes in pain outcomes from exposure to an adapted intervention, Cancer Health Empowerment for Living without Pain (CA-HELP), to improve patients’ communication about pain to their clinicians.

Design, Setting, and Participants   Older adults with cancer (aged ≥65 years) who were residing in a noninstitutional rural setting and receiving outpatient care at a rural-based clinic in Tennessee were enrolled in the study, in which everyone received the intervention, in May 2022. All patients were given assessments at baseline and 1 week after intervention. Mean score differences were analyzed using 1-tailed paired sample t tests (α = .05). Data were analyzed in June 2022.

Exposure   The adapted version of CA-HELP included an 18-page patient-facing workbook and a 30-minute telephone coaching call with a registered nurse to coach patients on pain education and communication techniques to discuss pain with their medical team.

Main Outcomes and Measures   Feasibility was examined through accrual and completion rates. Acceptability was measured by helpfulness, difficulty, and satisfaction with the intervention. Changes in outcomes were measured using mean score differences from pre-post assessments of pain self-management, self-efficacy for communicating with clinicians about pain, patient-reported pain, and misconceptions about pain.

Results   Among the 30 total participants, the mean (SD) age was 73.0 (5.1) years; 17 participants (56.7%) were female, 5 (16.7%) were Black or African American, 30 (100%) were non-Hispanic or non-Latino, 24 (80.0%) were White, 16 (53.3%) had less than a high school education, and 15 (50.0%) reported income less than $21 000 per year. Based on accrual and completion rates of 100%, this intervention was highly feasible. Fidelity rates for delivering intervention components (100%) and communication competence (27 participants [90%]) were also high. Regarding acceptability, all patients rated the intervention as helpful, with the majority (24 participants [80%]) rating it as “very helpful.” Most patients rated the intervention as “not at all difficult” (27 participants [90%]), enjoyed participating (21 participants [70%]), and reported being “very satisfied” (25 participants [83.3%]). Pre-post changes in outcomes suggested significant improvements in pain self-management and self-efficacy for communicating with clinicians about pain, as well as significant reductions in patient-reported pain and pain misconceptions.

Conclusions and Relevance   In this case-series study of CA-HELP, results suggested the adapted version of CA-HELP was feasible and acceptable and showed changes in pain-related outcome measures among older adults with cancer in a rural setting.

The burden of pain in people living with cancer is well documented, 1 , 2 and effective pain management is one of the largest population health challenges among older adults in the US. 3 - 10 It is estimated that as many as 80% of people diagnosed with cancer experience pain. 11 Among the older adult population living in the rural US, undertreated cancer pain is especially common. 12 , 13 Older adults living in rural areas are disproportionately affected due to concerns about the overuse of pain medication, 5 less access to care, 6 preferences for nonpharmacological interventions, 8 and reluctance to talk about pain. 14

Older adults with cancer are commonly afraid to voice pain concerns as they believe it reflects worsening cancer, is just part of life, and do not want to burden others. 1 , 12 , 13 , 15 , 16 As such, older adults may experience greater pain burden than the general patient population with cancer due to failing to bring up pain management as a concern to their clinicians. Further burdening older adults in rural settings is the reality that communication about pain in these settings exists against the backdrop of a growing opioid crisis that disproportionately impacts these communities. 17 , 18 This backdrop can impact patients’ willingness to seek out pain management and clinicians’ need for considering nonpharmacological treatment options to manage pain. There is an urgent need for interventions targeting pain management communication between older adults with cancer in rural communities and their clinicians; however, this need outpaces the current evidence base.

To address this need, we conducted a National Institutes of Health (NIH)–funded pilot study to adapt and test a promising evidence-based intervention, Cancer Health Empowerment for Living without Pain (CA-HELP). Prior research indicates CA-HELP demonstrated significant improvement among patients with cancer in their self-efficacy to communicate with their physicians about their pain. 19 , 20 Grounded in social-cognitive theory, 21 , 22 which posits that behavior change and maintenance depends largely on individuals’ ability and self-efficacy to execute a specific behavior, CA-HELP coaches patients to ask questions, make requests, and signal distress to their clinicians to achieve improved cancer pain control. Although a promising tool among older adults with cancer, the original CA-HELP intervention was not designed for optimal implementation in rural settings or among older adults.

We adapted the CA-HELP (CA-HELP-A) 23 to the older adult patient population with cancer in rural settings using the Method for Program Adaptation through Community Engagement (M-PACE) 24 , 25 model by partnering with older adult patients with cancer, their informal caregivers, and clinicians. Based on their feedback, modifications were made to the original intervention using the Framework for Reporting Adaptations and Modifications-Enhanced 26 model. The adapted version was tailored to meet the needs of older adults in rural settings, which is outlined in the original article. 23

The goal of the present study was to pilot test the adapted version of the intervention, which included a patient workbook and 30-minute telephone call with a nurse interventionist, in a busy rural cancer clinic with older adults with cancer. Based on prior work, our hypotheses were that the CA-HELP-A intervention would be highly feasible and acceptable. Although the focus of this study was to examine feasibility and acceptability, we also explored if there were significant improvements in pain self-management and self-efficacy to communicate about pain with clinicians as well as reductions in patient-reported pain and pain misconceptions.

All study procedures were approved by the institutional review board of Maury Regional Medical Center, Columbia, Tennessee. All participants provided informed consent and were recruited in May 2022 from an outpatient oncology clinic in rural Tennessee. Study staff conducted medical record reviews through the electronic medical record (EMR) to identify eligible patients. Eligibility criteria for patients included (1) receiving a diagnosis of cancer, (2) being aged 65 years or older, (3) speaking English, (4) residing in a noninstitutional rural setting, (5) receiving care at a community-based rural clinic, and (6) being able to provide informed consent. Exclusion criteria included (1) severe cognitive impairment (as indicated by medical team members) and (2) receiving hospice at the time of enrollment. Based on these eligibility criteria, patients were able to receive palliative care consultations or treatment during the course of the study. Study participants consented verbally via telephone or in person. This was an open group study; thus, all study participants received the study intervention. This study followed the reporting guideline for case series.

After consenting to the study, participants were given a baseline questionnaire assessing demographics, clinical characteristics, and targeted primary outcome (pain self-management) and secondary outcomes (self-efficacy for communicating with physicians about pain, pain misconceptions, and patient-reported pain). Next, participants were given a printed copy of the patient intervention (CA-HELP-A) workbook either in person or via mail. After receiving this workbook, participants engaged in a 30-minute intervention session over the telephone with a study staff nurse focused on reviewing modules and exercises included in the workbook. The nurse was a clinical lead in the palliative care clinic and thus was knowledgeable about pain management. Finally, after completing the intervention session, participants completed a postintervention assessment that included primary and secondary outcomes as well as measures of acceptability. Assessments were conducted in person or via the telephone by study staff. Because the primary goal of the study was to test the feasibility and acceptability of the intervention, the proposed sample size was 30. This number was selected based on recommendations in the Obesity-Related Behavioral Intervention Trials (ORBIT) model of research for developing and testing behavioral interventions. 27 This study set out to complete phase IIa (proof-of-concept) of the ORBIT model, in which the study goal is to focus on delivering a treatment-only design. 27 The ORBIT model deems sample size calculations to be unnecessary during this phase since the focus is on testing the feasibility of delivering the intervention.

The original CA-HELP is an evidence-based communication tool that empowers and engages patients to communicate effectively with their physicians about pain. 17 , 18 This intervention consists of 6 modules: (1) assessment of current knowledge, attitudes, and preferences around pain control; (2) clarification and correction of misconceptions about cancer pain control; (3) teaching of relevant concepts (education about cancer pain control); (4) planning (identifying pain goals, creating achievable pain management goals, and creating strategies to communicate these goals to clinicians); (5) rehearsal of communication strategies using role play exercises; and (6) portrayal of learned skills (patient applies skills in visit with health care clinician). We adapted this original version to meet the needs of older adults with cancer receiving care in rural settings. 23 Major modifications from the original CA-HELP intervention to the current version (CA-HELP-A) included adding a patient-facing workbook to guide the intervention session and inclusion of visual imagery, reduced number of words and complexity to meet a sixth grade reading level, stigma around pain management, and acknowledgment that pain should not be normalized due to age or disease status. The adapted version of the intervention was pilot tested in the present study.

This adapted version (CA-HELP-A) resulted in an 18-page patient-facing workbook, of which 9 pages include active materials (eg, learning content or exercises). The workbook consisted of 5 modules, instead of 6, which were collectively retitled “5 Steps for Talking with Your Doctor about Pain When Living with Cancer” with each module renamed to “Steps” based on patient and informal caregiver feedback. The 5 steps include step 1: checking awareness (action), step 2: clarifying (correct), step 3: gaining knowledge (learn), step 4: setting goals (plan), and step 5: talking to your doctor (practice). The final version of the patient workbook was composed largely of image-based communication, including pain scale ratings based on imagery and color, assessments based on worries (thumbs up or down ratings), and exercises to determine pain management approaches patients would like to have and setting goals and strategies for talking to their clinician.

Patients self-reported their age (in years), sex (male/female), ethnicity (Hispanic/Latino vs non-Hispanic/non-Latino), race (American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, White, multiracial, other [Hispanic or Latino/Latina], or other), relationship status, employment status, highest education level completed, total household income, insurance status (insured vs not insured), and primary treatment payment type. Race and ethnicity were assessed in this study to clearly outline sociodemographics of the patient population served and recruited. Disease characteristics were extracted from the EMR, including comorbidity status, cancer type and site, current cancer stage, presence of metastasis (yes vs no), and pain medication usage. Performance status was also extracted from the medical record and assessed with the Eastern Cooperative Oncology Group (ECOG) 28 , 29 and/or Karnofsky performance status. 30

Intervention feasibility was assessed with accrual and intervention and study procedure completion rates. Acceptability was assessed postintervention. Participants rated the overall perceived helpfulness of the intervention and satisfaction with the intervention. The helpfulness item was rated on a 5-point scale from 1, not at all helpful, to 5, very helpful (“Overall, how helpful was the intervention to you?”). The satisfaction item was rated on a 5-point scale from 1, not at all satisfied, to 5, very satisfied (“How satisfied were you with the intervention?”). Additionally, participants rated the intervention difficulty with a single item (“How difficult was it for you to understand the content of the intervention?”; 1, not at all, to 5, very much). Additional features of the intervention were rated including satisfaction with session length, satisfaction with amount of session information, intervention delivery modality (in person or phone), workbook modality (paper vs electronic or online version), and preference for inclusion of a caregiver.

Treatment fidelity was assessed with a checklist that captured whether: (1) the interventionist demonstrated communication consistency (eg, pacing, volume, and introduction to the purpose of the intervention), and (2) delivered core intervention components. These checklists were completed for all intervention sessions by trained fidelity raters who listened to audio recordings of the intervention sessions. Fidelity was defined as delivering 70% or more of intervention components and using 70% or more of the therapeutic techniques.

Pain self-management, which is the targeted primary outcome for future trials, was measured using 2 items from the pain management subscale of the Chronic Pain Self-Efficacy scale. 20 Items on this scale are rated on a 5-point Likert scale (1, not at all certain, to 5, extremely certain) in which patients rate the degree of certainty they have about their ability to manage their pain (eg, “How certain are you that you can decrease your pain quite a bit?”).

Self-efficacy for communicating with physicians about pain was assessed using the 5-item Perceived Efficacy in Patient-Physician Interactions scale 31 as modified to refer to communication with oncologists. 20 Items are rated on a 5-point Likert scale (1, not at all confident, to 5, very confident) in which patients indicate how confident they are about communicating with their physician (eg, “How confident are you in your ability to know what questions to ask your cancer doctor?”).

Pain misconceptions were assessed using 11 items based on the Short Form Barriers Questionnaire (SBQ). 32 Items are rated on a 5-point Likert scale (1, disagree very much, to 5, agree very much) in which patients indicate the degree to which they agree with certain statements about pain (eg, “It doesn’t do any good to talk about pain”). Patient-reported pain was assessed as the mean of the average and worst pain over the past 2 weeks on a 0 to 10 scale (0, no pain to 10, worst pain imaginable). 20

Descriptive statistics were used to examine demographic, disease, and clinical characteristics. Mean score differences were examined between preintervention and postintervention outcomes using 1-tailed paired sample t tests. Significance was set an α level of .05. Individual t tests were run for each of the following outcomes: pain self-management, self-efficacy to communicate about pain, pain misconceptions, and patient-reported pain. In regard to missing data, 1 participant was removed from the pain severity subscale analysis due to missing postseverity scores. Data were analyzed in December 2022 with R version 4.2.1 (R Project for Statistical Computing).

A total of 30 patients were enrolled in the study and completed the intervention. They had a mean (SD) age of 73.0 (5.1) years; 17 (56.7%) were female, 5 (16.7%) were Black or African American, 30 (100%) were non-Hispanic or non-Latino, 24 (80.0%) were White, and 16 (53.3%) were married or partnered. Most patients had a high school education or less (16 patients [53.3%]) and reported being low income, with 15 (50.0%) reporting a household income of less than $21 000 and 14 (46.7%) reporting a household income of $21 000 to $39 000. In terms of disease and clinical characteristics, patients had a mean (SD) Karnofsky score of 8.0 (1.9) and ECOG score of 1.0 (1.0). The largest portion of patients were stage IV (12 patients [40.0%]) and most patients were not currently taking pain medications (21 patients [70.0%]). See the Table for all patient demographic, disease, and clinical characteristics.

Feasibility was defined as 70% or more of eligible participants enrolling in the study, as well as 70% or more of enrolled participants completing the intervention. Study staff attempted to reach 39 patients for the study. Of those, 5 were deemed ineligible due to age or death, and 4 refused to participate. Thus, a total of 30 participants were eligible and consented. All 30 consented participants enrolled in the study and completed baseline assessments, the intervention session, and postintervention assessments. There were no patients lost to follow-up.

Regarding acceptability, all 30 participants rated the intervention as helpful, with the majority (24) rating it as “very helpful” (mean [SD] score, 4.80 [0.50]). Overall, 25 participants (83.3%) reported being “very satisfied” with the intervention (mean [SD] score, 4.70 [0.64]), and 21 (70.0%) reported enjoying participating in the intervention. Most participants (28 patients [93.3%]) found 1 session to be the right length and found the intervention to contain the right amount of information. Most participants (27 patients [90.0%]) rated the content of the intervention as “not at all difficult” to understand (mean [SD] score, 1.3 [1.02]). The 3 participants who indicated some degree of difficulty did not specify the aspects they found difficult to understand.

A total of 26 participants (86.7%) indicated a preference for either an in-person or phone session with a health coach, nurse, or social worker. Almost all participants (29 patients [96.7%]) preferred receiving a paper version of the workbook over an electronic or online version. Finally, a total of 25 participants (83.3%) indicated they would have liked participating in the session with a caregiver or loved one.

Fidelity was defined as using 70% or more of the communication competencies and delivering 70% or more of core intervention components. Fidelity rates of 90% for communication consistency (pacing, volume, and introduction to purpose of intervention) and 100% for delivery of intervention components were observed, meeting the benchmarks for treatment fidelity across both categories.

A total of 30 patients were enrolled, adequately powering this study (0.85) to detect moderate effect size differences. Pre-post changes in outcomes suggested significant improvements in pain self-management and self-efficacy for communicating with physicians about pain, as well as significant reductions in patient-reported pain and pain misconceptions. Pain self-management scores saw a mean (SD) total score increase of 1.8 (1.45) points ( t 29  = 6.809; P  < .001). Patient-reported pain scores had a mean (SD) score difference of 0.5 (1.57) points ( t 28  = 1.715; P  = .049). Pain misconception scores had a mean (SD) score difference of 1.4 (0.43) points ( t 29  = 18.281; P  < .001). Finally, scores for self-efficacy for communicating with physicians about pain had a mean (SD) score increase of 2.8 (2.86) points ( t 29  = 5.297; P  < .001). See the Figure for a visualization of results from this pilot study.

In this case-series study among older adults with cancer in rural settings, we examined the feasibility, acceptability, fidelity, and pre-post results of a communication-based intervention designed to improve pain self-management and pain communication with clinicians among older adults with cancer receiving care in rural settings. Results suggested the adapted version of CA-HELP (CA-HELP-A) was feasible, acceptable, had high rates of intervention fidelity, and demonstrated potential efficacy at improving targeted pain outcomes. Rates of enrollment (88.2%) and completion of intervention sessions and study procedures (100.0%) were outstanding, demonstrating high rates of feasibility among this difficult-to-reach population. Patients also reported high rates of acceptability, including rating satisfaction with the intervention and helpfulness of the intervention highly and difficulty of the intervention low. Additionally, most participants reported enjoying participating in the intervention and preferring the chosen mode of intervention delivery (telephone) as well as workbook medium (printed, hard copy).

Most promising, study results suggest significant improvements in patients’ self-reported pain self-management and self-efficacy to communicate with physicians about pain as well as significant decreases in pain misconceptions and patient-reported pain. These results suggest that CA-HELP-A may be an effective intervention at improving multiple pain outcomes among older adults with cancer living and receiving care in rural settings. Given the high rates of undertreated cancer pain among older adults living in the rural US, 12 , 13 the results of this pilot study are especially promising. Improving the capacity of rural clinics to identify older adults with cancer who are experiencing pain and are most likely to benefit from a pain management communication intervention is a high value proposition. These are heavily burdened clinics with very limited resources, often serving large catchment areas where patients must travel long distances to receive care.

Our adapted intervention (CA-HELP-A) is a low burden, light touch, fully remote, and potentially effective intervention for improving pain management among older adults in these settings. CA-HELP-A coaches patients in how to have conversations about their pain with their clinicians and develop an action plan to comanage it. As such, it is agnostic to pain intervention type. This allows patients to have honest conversations with their clinicians about their pain to find the best pain management approach for each patient. This holds promise for intervening on pain in a variety of ways, including using nonpharmacological approaches, which are the most commonly preferred methods of pain management among this vulnerable population. 8 Additionally, this intervention could help address patients’ reluctance to talk about pain, 14 overcome their misconceptions that pain is just a part of life, 1 , 12 , 13 , 15 , 16 and bring up conversations about pain in a way that is destigmatizing amidst the growing opioid crisis affecting rural communities. 17 , 18 CA-HELP-A is designed to target these barriers by encouraging patients to talk with their clinicians about their pain needs and to explore multiple options for pain management, including both opioids and nonpharmacological treatments. Future research should examine how the CA-HELP-A differs in potential efficacy among those taking pain medications vs those who are not. This may provide further insight on how to best target patients most in need of interventions to reduce their pain severity and improve their pain self-management. Additionally, future randomized clinical trials testing the efficacy of CA-HELP-A compared with a control condition should examine differences in how this intervention affects pain-related outcomes among patients based on disease severity (eg, early stage vs advanced metastatic cancer) and source of pain (eg, surgery, chemotherapy, radiation, or other chronic conditions).

Despite promising results, there are limitations that must be acknowledged in interpreting results of this study. First, although this sample was diverse in terms of education and income, it was less diverse racially and ethnically. The sample was predominately White and non-Hispanic/non-Latino. This is reflective of the study setting in rural Tennessee. Nevertheless, future research should examine the feasibility, acceptability, and potential efficacy of CA-HELP-A among more racially and ethnically diverse samples. Second, the CA-HELP-A intervention was only available and tested among English-speaking patients. Future work should expand this to include Spanish translations of the workbook to determine its potential utility among Spanish-speaking older adults in rural settings. Additionally, the sample size and pre-post design limit the ability to examine the efficacy of CA-HELP-A, control for key factors such as demographic variables that could impact treatment outcomes (eg, time, age, and disease severity), and generalize study findings. The main focus of the present study was on phase IIa (proof-of-concept) of the ORBIT guide for developing and testing behavioral interventions. 27 In this phase, the goal of the study is to determine the feasibility of delivering the intervention and the intervention protocol, thus there is a lack of a control group to more stringently test the potential efficacy of the intervention relative to a control condition. Given this limitation, results around potential efficacy should be interpreted with caution. Future trials should examine the efficacy of CA-HELP-A among multiple sites with multiple patients.

Preliminary evidence from this case-series study suggests that the CA-HELP-A intervention we adapted was highly feasible, acceptable, and significantly improved pain self-management and self-efficacy to communicate about pain with physicians and reduced patients’ self-reported pain and pain misconceptions. This holds great promise for addressing the urgent need to support the growing older adult population experiencing undertreated cancer pain.

Accepted for Publication: May 10, 2024.

Published: July 17, 2024. doi:10.1001/jamanetworkopen.2024.21298

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Shen MJ et al. JAMA Network Open .

Corresponding Author: Megan J. Shen, PhD, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Mail Stop D5-290, Seattle, WA 98109 ( [email protected] ).

Author Contributions: Dr Shen and Ms Yarborough had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Shen, Harrison.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Shen, Harrison.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Yarborough, Harrison.

Obtained funding: Shen, Harrison.

Administrative, technical, or material support: Stokes, Harrison.

Supervision: Shen, Stokes, Harrison.

Conflict of Interest Disclosures: Dr Stokes reported receiving grants from Maury Regional Medical Center during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was funded through a pilot award by the Cornell Roybal Center-Translational Research Institute on Pain in Later Life (National Institute on Aging No. P30AG022845) and a National Cancer Institute career award (No. K07CA20758 to Dr Shen).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See the Supplement .

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