Barry University How Role of EBL Facilitate Organization Change to New Paradigm Of EBP Discussion

  

Description

Describe how the unique role of evidence-based leadership (EBL) can facilitate an organization change to the new paradigm of EBP.

Chapter 19 describes the similarities of the EBP and evidenced-informed health policy (EIHP) processes. Provide a summary of a policy problem and formulate the policy problem into a policy PICOT question.

Original Article
An Integrative Review of Interventions for
Enhancing Leadership in the Implementation
of Evidence-­Based Nursing
Tarja Välimäki, PhD, RN
●
Pirjo Partanen, PhD, RN ● Arja Häggman-Laitila, PhD, RN
ABSTRACT
Key words
evidence-based
practice,
administration/
management/
leadership/
organization,
evidence-based
nursing, research
utilization,
intervention research,
nursing practice,
policy development/
policymaking
Background: The most common barriers to evidence-­based nursing (EBN) are related to nurse
leadership and to organizational characteristics. Scientific evidence is needed regarding interventions that support nurse leadership.
Aims: The aim was to gather, assess, and synthesize the current empirical evidence regarding
interventions for enhancing nursing leadership in EBN implementation.
Methods: We conducted an integrative review of interventions that enhance the roles of nurse
leaders in EBN implementation using reporting guidance according to the PRISMA
statement.
Results: The search identified five studies, which described two intervention types: interventions improving nurse leaders’ capabilities for EBN implementation and supporting the activities for EBN implementing. The interventions focused on strategic, teamwork, and individual
levels. All interventions produced positive outcomes on primary outcomes, however all not
statistically significant.
Linking Evidence to Action: The studies mainly had descriptive designs and short follow-­up
times, so it was not possible to propose evidence-­based recommendations for effective interventions. The certainty of evidence was very low due to the study designs and the risk of bias.
Structured clinical education might promote new innovations in evidence-­based leadership in
nursing. Conclusions about the impact of the interventions must be drawn with caution. They
might be useful for promoting the abilities of nurse leaders to implement EBN, but further studies are needed to provide more reliable recommendations.
INTRODUCTION
Evidence-­based health care improves healthcare quality and
safety as well as patient outcomes, and it reduces costs and
enhances nurses’ professional satisfaction. However, despite all these benefits, nurses and nurse leaders do not consistently implement evidence-­based practices (EBP; Melnyk,
Fineout-­Overholt, Gallagher, & Kaplan, 2012). According to
a recent survey study (Melnyk et al., 2016), nurse leaders’
(CNOs, CNEs) own implementation of EBP in their organizations remained relatively low. Although the CNEs and
CNOs stated that their highest priorities were quality and
safety, EBP was not listed as a top priority, and the budget allocations were low for implementing and sustaining
evidence-­based care.
According to the systematic review of Carlson and
Plonczynski (2008), the most common barriers to evidence-­
based nursing (EBN) are related to the characteristics of
the organization. Specifically, nurses do not have enough
time to read and implement research knowledge, they lack
the authority to change patient care procedures, and they
lack support from physicians, managers, and other staff
424
(Melnyk et al., 2012). One recently identified barrier to EBP
is resistance to EBP by nurse leaders and managers (Melnyk
et al., 2012).
According to systematic reviews including studies published approximately a decade ago (1995–2007) in various
target groups, there were few reports on the roles of nurse
leaders or on interventions aiming to support nurse leaders and healthcare infrastructure (Flodgren, Roja-­
Reyes,
Cole, & Foxcroft, 2012; Gifford, Davies, Edwards, Griffin, &
Lybanon, 2007; Halm, 2010; Sandström, Borglin, Nilsson,
& Willman, 2011). Taken together, these reviews emphasize
that the role of leadership is poorly defined in EBP leadership (Sandström et al., 2011), with only two studies explicitly focusing on leadership-­related EBP behaviors (Gifford
et al., 2007; Halm, 2010). Leadership is defined according
to Gifford et al. (2007) as multidimensional process of influence to enable nurses to use research evidence in clinical
practice. Melnyk et al. (2012) pointed out that compared to
nurses in non-­magnet institutions, nurses in magnet institutions report more consistent implementation of EBP by
their healthcare system, greater availability of EBP experts,
Worldviews on Evidence-Based Nursing, 2018; 15:6, 424–431.
© 2018 Sigma Theta Tau International
Original Article
an organizational culture that is more supportive of EBP,
more routine EBP educational offerings, and more routine
recognition of EBP efforts. Although studies suggest that
nurse leaders should play a key role in EBN (Dale et al.,
2015; Higuchi, Downey, Davies, Bajnok, & Waggott, 2012;
Matthew-­Maich, Ploeg, Jack, & Dobbins, 2012), the nature
of this role has not yet been fully identified (Wilkinson,
Nutley, & Davies, 2011).
Although accumulating interest on the implementation
of EBP, we did not find any recent reviews reporting on
interventions aiming to enhance nursing leadership in the
implementation of EBP.
The aim of this integrative review was to gather, assess, and synthesize current empirical evidence regarding
interventions that enhance nursing leadership in the implementation of EBP. Our specific research questions for
this review were as follows: (a) What kinds of interventions
have been used to improve nurse leadership in the implementation of EBN? (b) What outcomes have been achieved
using these interventions?
THE REVIEW
Design
The design involved an integrative review (Whittemore &
Knafl, 2005) using reporting guidance according to the
PRISMA statement that covers evidence-­based minimum
set of items for reporting particularly evaluations of interventions (Moher, Liberates, Tetzlaff, & Altman, 2009).
Search Terms
Four databases that were searched are as follows: the
Cochrane Library, CINAHL, PubMed MEDLINE, and
SCOPUS. The search was limited to papers published from
January 1, 2008, to August 29, 2017. Table S1 describes the
search terms and the search results. An additional manual
search was conducted on reference lists from retrieved articles and journals. Data search was completed in August
2017.
Eligibility Criteria
To be included in the review, the full text of the study had
to show that the study met the following inclusion criteria:
(a) The study describes an intervention for implementation
of EBP or EBN; (b) the study describes nurse leaders as a
target group; (c) the study was an empirical study; and (d)
the study had no methodological restrictions (Table S2).
Search Outcome
The searches identified 989 studies that were reviewed by
three authors based on the criteria. The selection process
is described in Figure 1. Five articles were included in the
final analysis (Table S3).
Publication Quality Appraisal
Publication quality (Table S3) was evaluated using the criteria presented by Gifford et al. (2007), and the studies were
ranked as excellent (2 points), as having some limitations
Worldviews on Evidence-Based Nursing, 2018; 15:6, 424–431.
© 2018 Sigma Theta Tau International
(1 point), or as having many limitations (0 points). When
the study had methodological triangulation, the study quality was graded based on the predominant method in the
study. Surveys were evaluated with six criteria. Studies receiving 9–12 points were evaluated as excellent, 5–8 points
indicated some limitations, and 0–4 points meant many
limitations. Qualitative studies were evaluated with 11 criteria. Studies receiving 16–22 points were evaluated as excellent, 9–15 points as having some limitations, and 0–8
points as containing many limitations. Studies were evaluated as excellent (Hauck, Winsett, & Kuric, 2013; Wallen
et al., 2010) or with some limitations (Gifford, Davies,
Tourangeau, & Lefebre, 2011; Gifford et al., 2013; Kvist,
Tähkä, Ruotsalainen, & Tervo-­Heikkinen, 2014).
Assessment of Bias and Certainty of Evidence
The risk of bias was evaluated in three studies (Gifford
et al., 2011; Hauck et al., 2013; Wallen et al., 2010) according to the study designs using Cochrane Risk of Bias Tool
(Effective Practice and Organization of Care, 2017). The authors made final decisions on the level of bias together. One
study (Gifford et al., 2013) was excluded from the assessment because it was a qualitative one and one (Kvist et al.,
2014) because it did not report statistical differences between measurements at two time points. One randomized
controlled trial (RCT) was evaluated with nine criteria, and
two interrupted time series (ITS) studies with seven criteria. There was very serious and mixed or unclear risk of bias
in all included studies. In the RCT, the baseline measurements were not conducted. In two ITS studies, sample sizes
were sufficient to the conducted analysis, but the interventions were not independent of other changes in time. The
Grades of Recommendation Assessment, Development, and
Evaluation (GRADE) approach was used to rate the certainty
of evidence of the intervention outcomes. The criteria were
as follows: study design, risk of bias, indirectness, imprecision, and publication quality. Scores ranged between −1
and +1 and were added together to total score. The score 1
is the lowest, and 4 the highest (Cochrane Effective Practice
and Organisation of Care, 2017; Table 1).
Data Abstraction and Narrative Summaries
All relevant articles were reviewed, and the data were extracted from the empirical studies into a descriptive matrix
of the full texts (Table S3). Due to the divergent methodologies of the included studies, a narrative summary was used
to describe the content of the studies at the analysis stage
(Whittemore & Knafl, 2005).
RESULTS
Characteristics of the Included Studies
The studies were published between 2010 and 2014. Two
were conducted in the United States, one in Finland, and
two in Canada. The majority of the studies were conducted in hospital settings, whereas one project, reported
in two papers, was conducted in a home and community
425
Identification
Nurse Leadership Interventions in EBN
Records identified through
database searches
(n = 989)
Screening
After duplications removed
Abstracts excluded
(n = 78)
Abstracts screened for
inclusion
(n = 152)
Full-text articles excluded
based on criteria
(n = 67)
Eligibility
Full-text articles
assessed for eligibility
(n = 74)
Full-text articles included
(n = 8)
Included
Studies included by manual
search
Full-text articles excluded
based on poor quality (n = 1)
or that did not meet inclusion
criteria (n = 2)
Studies included in
analysis)
(n = 5)
Figure 1. PRISMA flow diagram of the study selection process. [Correction added on October 26, 2018 after
first online publication October 15, 2018. In Figure 1, Full Text articles was updated from n=7 to n=8.] [Colour
figure can be viewed at wileyonlinelibrary.com]
Table 1. Assessment of the Certainty of Evidence (GRADE)
No. of
studies
Design
(scores of
design)
Risk of bias
Inconsistency
Indirectness
Imprecision
Publication
bias
Certainty
rating
Interventions to support activities of nurse leaders in implementing EB
Outcomes: In one study, a primary outcome not set for the intervention (ITS). Leadership and management behaviors (RCT).
Implementation of EBP in a clinical research-­intensive environment (ITS)
3
RCT (4)
ITS (2)
2 very serious
risk of bias:
unclear/low
risk of bias in
RCT. Mixed
risk of bias in
one ITS
1 serious risk of
bias.
Inconsistency
between the
content of the
interventions
measurements
and primary
outcomes
No serious,
follow-­up
periods from
12 weeks up
to 2 years
Sample sizes
Excellent in
from 99 to 469
two ITS,
in two ITS. No
some
confidence
limitations
intervals
in RCT
available in two
study (RCT, ITS).
Effect size for
post-­intervention
scores in one ITS
Very low
(1)
Note. RCT = randomized controlled trial; ITS = interrupted time series.
426
Worldviews on Evidence-Based Nursing, 2018; 15:6, 424–431.
© 2018 Sigma Theta Tau International
Original Article
healthcare organization. The study designs were descriptive, one had an experimental design, and two had quasi-­
experimental designs without control groups (Table S3).
The sample sizes in the evaluation phase were small, varying from 13 to 159 participants. The interventions were
evaluated using questionnaire surveys. Four of the studies used validated scales (Table S4). In addition, qualitative
evaluation data were gathered by focus group discussions,
interviews, telephone interviews, and open questions in
a survey.
Interventions That Aimed to Improve Nurse
Leaders’ Capabilities for EBN Implementation
A 9-­month-­long evidence-based nursing leadership (EBNL)
training intervention was used in one study (Kvist et al.,
2014). The study was a longitudinal descriptive intervention study with pre-­and post-­intervention surveys. The
intervention consisted of EBNL lectures given by academic
and service sector experts and researchers, and small working groups were given developmental assignments. The intervention used a Web-­based learning environment as well
as advanced mentors that supervised the clinical group assignment (Table S3).
The intervention outcome in this study had two goals:
first, to help nurse leaders identify their roles as leaders in
EBP; and second, to increase the nurse leaders’ knowledge
of EBL and EBP, to help them promote EBL and EBP in their
units, and to train the nurse leaders to utilize research information. The majority of the nurse leaders (59%) agreed
that the EBL training helped them understand that healthcare decisions can be justified with research knowledge.
Further, the participants reported that the intervention
improved their development as EB leaders (91% agreed or
totally agreed).
After the training, the nurse leaders reported greater
recognition of their responsibility to develop EPB (88%–
100% agreement for each item) and reported that they had
improved their skills in terms of supporting staff, setting
an example in their working unit, and developing collaboration (24%–27% totally agreed). The nurse leaders understood the role that they play in changing the culture and
implementing EPB, although acknowledging it takes time
and passion to change their leadership style. The strength
of evidence was weak due to the study design.
Interventions That Were Conducted to
Support the Activities of Nurse Leaders in
Implementing EBN
Four studies had interventions that targeted the activities
of nurse managers or leaders as well as various types of
nurses, and clinical educators who had leadership roles.
The interventions covered both group-­based methods and
methods for individuals. Conducted interventions focused
on different levels on organizations: strategic level (Hauck
et al., 2013), teamwork (Gifford et al., 2011, 2013), and
mentorship (Wallen et al., 2010).
Worldviews on Evidence-Based Nursing, 2018; 15:6, 424–431.
© 2018 Sigma Theta Tau International
In the study by Hauck et al. (2013), a prospective descriptive comparative design was used to assess nurses’
beliefs regarding the importance of EBP, the frequency of
EBP use, and the perception of organization readiness for
EBP (Table S3). The Nursing Research/EBP Committee developed and directed a strategic plan that addressed EBP
enculturation based on the literature. The actions of nurse
leaders to promote EBP included elements of strategic leadership as well as steps to enable education and collaboration. The outcomes were set a priori to meet seven strategy
goals. The study reported the achievement of targets that
were set for the strategic plan and the comparisons of survey results according to the job or role of the participants.
The survey results indicated that the score for having a culture that supported EBP increased significantly from baseline mean score 3.10 (0.96) to 3.70 (0.77); F(1.896) = 128.1;
p < .001. There was a statistically significant difference for the total group scores during the follow-­up. The mean score increased from 3.61 (1.49) to 6.40 (1.6); F(1.640) = 521.4; p < .001 (a score of 1 indicated not ready for action, and a score of 5 indicated being ready for action). The strategic plan was successful in that it created a culture that supported EBP, and it highlighted that it is important to conduct a careful evaluation of leadership at the first step of the intervention. There is insufficient evidence regarding the effect of enculturation of EBP. The results of Hauck et al. (2013) showed only a small improvement in the director or leader nurse’s group for beliefs in the importance of EBP, because the baseline scores were high. The authors suggest that belief in the importance of EBP, the skills to implement EBP, and the confidence in one’s ability to implement EBP were therefore not affected by the intervention. As a group, the respondents showed a 7% increase in achieving the strategic plan target. However, actual EBP implementation was not improved. Gifford et al. (2011, 2013) described a systematically developed leadership-­focused intervention (Table S3). The aim of the leadership intervention was to facilitate nurses’ use of guideline recommendations for diabetic foot ulcers. First, the pilot study (Gifford et al., 2013) tested the feasibility of conducting a cluster randomized controlled trial to evaluate the influence of a leadership intervention in nurses’ use of guideline recommendations in home care settings. However, leadership and management behaviors were assessed through interviews. Compared to the control group, the experimental group reported more relations-­ oriented leadership behavior and more use of feedback, audit, and reminders as leadership strategies. The conducted intervention (Gifford et al., 2011) validated the importance of teamwork as well as the role of each nurse leader in supporting an EBN implementation. The intervention was rated using a 4-­ point scale that ranged from 1 (not at all relevant or useful) to 4 (extremely useful and relevant). Identification of target indicators had the highest 427 Nurse Leadership Interventions in EBN mean score, 3.7, and the following each had mean scores of 3.5: development of a team leadership action, discussions of barriers and leadership support, and charting audit findings about research or practice gaps. Thus, it seems to be critical to have leaders that support the implementation of EBP guidelines through leadership strategies. Three months after the intervention, all participants perceived that the intervention had influenced them as leaders that implement EBP guidelines (Gifford et al., 2011). Wallen et al.’s (2010) study reported a program to enhance system-­wide EBP implementation and sustainability (Table S3). Further intervention consisted of a structured multifaceted mentorship program that utilized a quasi-­ experimental mixed-­ methods design. The intervention included workshops, lectures, and tutorials. Pre-­and post-­ intervention surveys were completed by participants in the EBP intervention group (n = 94 vs. n = 58, respectively) and comparison group (n = 65 vs. n = 41, respectively). There was a greater increase in the intervention group (77.2–89.5 points) than in the comparison group in perceived organizational culture and readiness for EBP (80.9–82.9 points; F = 5.09; p = .025). The combined EBP culture and readiness score increased in the entire sample (78.7–86.9; F = 9.55; p = .002). In terms of the EBP belief scores, the mentorship program group showed an increase of 7.4 points, whereas the control group showed an increase of 0.2 points (F = 5.09; p = .025) In addition, the qualitative findings suggested the importance of leadership support of a culture of EBP. All interventions produced positive outcomes on primary outcomes. The primary outcomes varied across studies, and different outcome measures were used. The certainty of evidence was very low (Table 1). It remains uncertain whether the interventions enhance the implementation of EBN by nurse leaders. DISCUSSION AND CLINICAL IMPLICATIONS The results of this integrative review indicate that there is still only scant scientific knowledge on the interventions targeting nurse leaders in implementation of EBP. Five different interventions were included in this review. Although positive outcomes were measured, the certainty of the evidence remains very low due to the weak study designs and risk of bias. The interventions may be beneficial, but the likelihood that the effect will be substantially different is high. Based on this, further studies are needed to provide more reliable recommendations for the healthcare personnel and policymakers for the use of interventions. The scarcity of research evidence regarding nurse leaders’ roles in EBN is understandable from the point of view of knowledge management. Only in the last two decades has knowledge management gained interest in academic research. In health care, disseminating and exchanging research evidence has been the main focus of knowledge 428 management (Ferlie, Crilly, Jashapara, & Peckham, 2012; Karamitri, Talias, & Bellali, 2017). It seems that the nurse leaders’ role is understudied (Lunden, Teräs, Kvist, & Häggman-­Laitila, 2017). The systematic reviews of Lunden et al. (2017) and Karamitri et al. (2017) were in accordance with earlier systematic reviews by Gifford et al. (2007) and Sandström et al. (2011) in pointing out that knowledge management is facilitated by an organizational culture that supports collaboration, sharing of information, learning together, and rewarding people for their achievements. These aspects are worth considering when developing interventions for nurse leaders on the implementation of EBN. There should be an emphasis on the relational aspects of leadership roles (Stetler, Ritchie, Rycroft-­Malone, & Charns, 2014; Van der Zijpp et al., 2016). In our review, we found only five different interventions, all of which were developed for a single study and were conducted once. The contents, teaching methods, and evaluation measurements of the interventions varied. The interventions combined two or more teaching or learning methods, reported to improve the effectiveness of educational interventions for EBN (Hines, Ramsbotham, & Coyer, 2015; Phillips et al., 2014; Young, Rohwer, Volmink, & Clarke, 2014). The accuracy of the descriptions of the interventions also varied in the different studies, and it was not always clear whether the interventions included all goals that were required for the five steps of EBN (Phillips et al., 2014). The conducted interventions were implemented to motivate at both the individual and team levels, and thus, to some extent, aimed to influence organizational factors. Leadership styles were also considered. The interventions in the studies we reviewed aimed to improve the knowledge, skills, and attitudes of nurse leaders toward EBP. The competencies, in terms of incorporating evidence into the decision-­making of patient care and on conducting change, were not prominent. This is a general weakness in interventions for EBN (Häggman-­ Laitila, Mattila, & Melender, 2016, 2017a, 2017b) and for EBP (Phillips et al., 2014; Young et al., 2014). Abdullah et al. (2014) and Melnyk, Fineout-­ Overholt, Giggleman, and Choy (2017) concluded that nurse leaders need close collaborations with a critical mass of EBN mentors to improve patient outcomes. The implementation of EBN is a complicated process, and it is important to use several simultaneous strategies that target nursing staff, leadership practices, organizational culture, and the availability and applicability of evidence (Dale et al., 2015; Häggman-­Laitila et al., 2017a, 2017b; Matthew-­Maich et al., 2012). In the future, more research is needed to investigate the effectiveness of interventions on patient care, to determine how simultaneous strategies support the effectiveness of interventions, and to standardize interventions and implement EBN processes. Attention should also be paid to the intervention development process. Worldviews on Evidence-Based Nursing, 2018; 15:6, 424–431. © 2018 Sigma Theta Tau International Original Article VALIDITY AND LIMITATIONS To ensure that the search process was systematic and extensive, the search strategy was carried out in cooperation with an academic library information retrieval expert utilizing database directories. The search terms were chosen to identify comprehensive studies that focused on the improvement of nurse leadership in the implementation of EBN and used the word indexes and special features of the databases. The search terms were reported accurately to ensure repeatability. Three researchers worked independently to select the studies and discussed ambiguous cases, which added to the reliability of the data. The articles were first identified based on their titles. The use of several databases decreased the likeliness of selection bias. Careful use of the matrix increased the reliability of the analysis. The validity of the intervention studies that were included in this review was strengthened by the use of quantitative and qualitative data collection methods in two studies (Gifford et al., 2011; Wallen et al., 2010) and previously developed and tested instruments in three studies (Hauck et al., 2013; Kvist et al., 2014; Wallen et al., 2010). In one study, a chart audit tool was developed for the purposes of the study (Gifford et al., 2007). Grey literature was not sought, and no contacts to study authors were made. These should be regarded as limitations of this review, because they might have resulted in missing ongoing studies. The other limitation might be the language selection criteria set for this review. As for limitations in the validity of the intervention studies that were included in this review, some of the studies had small sample sizes considering the study design (Gifford et al., 2011, 2013), and in one, the follow-­up period was short (Kvist et al., 2014). Gifford et al. (2013) did not report any baseline results in their RCT study. These factors may have skewed the evaluations of the interventions. The outcome evaluations were based mainly on self-­ assessments. The heterogeneity of interventions limited the synthesis of the results in this review. Very low certainty of evidence restricted the evaluations of the benefits of the interventions. CONCLUSIONS To conclude, there is a lack of strong evidence on interventions that target nurse leaders in the implementing of EBN. It is therefore not possible to give evidence-­based recommendations for effective interventions that could inform practice, future studies, and education. In the future, organizational aspects and leadership styles should be considered when developing interventions in addition to considering the learning goals of all five steps of EBN. Also, there is a need for detailed descriptions of the theoretical background, the content of the intervention, simultaneous strategies that are used to enhance the effectiveness of the interventions, the pedagogical methods, the learning contexts, and the measurements used to evaluate the Worldviews on Evidence-Based Nursing, 2018; 15:6, 424–431. © 2018 Sigma Theta Tau International interventions. Moreover, in interventions valid measurements are needed to assess the long-­term effectiveness in all EBN learning categories. It is imperative to evaluate the effectiveness of patient care. WVN LINKING EVIDENCE TO ACTION • Leadership roles and responsibilities depending on the organizational lever they are acting need take account in future studies. • The implementation of EBP needs to proceed through multiple concurrent strategies on individual and every organizational level. • It is necessary to enforce continuous training of EBP leadership in healthcare organizations. • Mixed-methods studies might give evidence on the effects on leadership practices on EBP. Author information Tarja Välimäki, University Researcher, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland; Pirjo Partanen, University Lecturer, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland; Arja Häggman-Laitila, Professor, Chief Nursing Officer, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland. 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What are the effects of teaching evidence-­ based health care (EBHC)? Overview of systematic reviews PLoS One, 9(1), e86706. https://doi.org/10.1371/journal.pone.0086706 10.1111/wvn.12331 WVN 2018;15:424–431 SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s web site: Table S1. The Search Strategy Used to Identify Studies of Interventions That Enhance the Roles of Nurse Leaders in Evidence-­ Based Practice Implementation Table S2. The Review Inclusion and Exclusion Criteria That Were Used to Identify Studies of Interventions That Enhance the Roles of Nurse Leaders in Evidence-­Based Practice Implementation Table S3. Overview of Studies of Interventions That Enhance the Roles/Impact of Nurse Leaders in Evidence-­Based Practice Implementation Table S4. Description of Outcome Measures Used to Enhance the Roles of Nurse Leaders in Evidence-­Based Practice Implementation Worldviews on Evidence-Based Nursing, 2018; 15:6, 424–431. © 2018 Sigma Theta Tau International 431 Copyright of Worldviews on Evidence-Based Nursing is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Purchase answer to see full attachment