Journal of Gerontological Nursing

Feature Article 

Nursing Work in Long-Term Care: An Integrative Review

Jed Montayre, PhD, RN; Jasmine Montayre, RN, CertT

Abstract

Evidence suggests that delivery of good nursing care in long-term care (LTC) facilities is reflected in nurses' descriptions of the factors and structures that affect their work. Understanding the contemporary nature of nursing work in aged care will influence policies for improving current work structures in this practice setting. The current review aims to present a contemporary perspective of RNs' work in LTC facilities. A comprehensive search and purposeful selection of the literature was conducted using CINAHL, PubMed, Medline, Scopus, and Google Scholar databases. Nine studies were eligible for review. Common themes revealed that nursing work in aged care settings is characterized by RNs providing indirect care tasks—primarily care coordination, engaging in non-nursing activities, and having an expanded and overlapping role. As care providers, aged care RNs do not always provide direct care as part of their nursing work. The scope of RN work beyond its clinical nature or performance of non-nursing tasks adds complexity in clarifying RN work roles in aged care. [Journal of Gerontological Nursing, 43(11), 41-49.]

Abstract

Evidence suggests that delivery of good nursing care in long-term care (LTC) facilities is reflected in nurses' descriptions of the factors and structures that affect their work. Understanding the contemporary nature of nursing work in aged care will influence policies for improving current work structures in this practice setting. The current review aims to present a contemporary perspective of RNs' work in LTC facilities. A comprehensive search and purposeful selection of the literature was conducted using CINAHL, PubMed, Medline, Scopus, and Google Scholar databases. Nine studies were eligible for review. Common themes revealed that nursing work in aged care settings is characterized by RNs providing indirect care tasks—primarily care coordination, engaging in non-nursing activities, and having an expanded and overlapping role. As care providers, aged care RNs do not always provide direct care as part of their nursing work. The scope of RN work beyond its clinical nature or performance of non-nursing tasks adds complexity in clarifying RN work roles in aged care. [Journal of Gerontological Nursing, 43(11), 41-49.]

The reality of how nurses perform their day-to-day tasks in their work roles and functions has been captured in the nursing literature. Crossan and Shacklock (2013) emphasized that understanding nurses' work has critical implications to improving health care outcomes. However, what nurses do and how they spend their time at work is affected by organizational complexities (Duffield, Gardner, & Catling-Paull, 2008). A review of observational studies about the tasks encompassing nursing work identified eight nursing activities, which were described as organization-centered and not exclusively patient-oriented (Allen, 2007). Furthermore, organizational work systems that nurses are exposed to are believed to be pushing them away from core values of compassion and care (Bogossian, Winters-Chang, & Tuckett, 2014). These overlapping complexities of nursing activities and functions have been long identified and are still recognizable in contemporary practice (Pearson, 2003).

Earlier research explored nursing work through work sampling methods (Duffield & Wise, 2003). Attention given to measuring nursing work continues, with current emphasis on appropriateness of the work sampling method in investigating nurses' tasks (Blay, Duffield, Gallagher, & Roche, 2014; Pelletier & Duffield, 2003). Time-and-motion studies were also used to uncover specific activities and amount of time nurses spent in their work (Abbey, Chaboyer, & Mitchell, 2012; Desjardins, Cardinal, Belzile, & McCusker, 2008; Hendrich et al., 2009; Yoon et al., 2015). Aside from use of diverse methodologies, nursing work was also explored together with other relevant variables and existing work issues, such as organizational changes and system and staffing problems (Duffield et al., 2008).

Most studies on nursing work were conducted in acute care settings (Chaboyer et al., 2008; Duffield et al., 2008; Farquharson et al., 2013; Shuriquie, While, & Fitzpatrick, 2008; White, Jackson, Besner, & Norris, 2015). Blay et al. (2014) systematically reviewed patterns of nursing work and nurses' workloads, which revealed an obvious underrepresentation of research evidence on nursing work in long-term care (LTC) settings. Studies conducted on nursing work in acute care environments were methodologically robust; however, they did not generalize or represent other fields of practice, such as gerontological nursing.

Similar to other practice settings, aged care nursing faces complexities with work issues, such as staffing shortages and challenges in provision of competent and quality care (Jones, Cheek, & Ballantyne, 2002; Schirm, Albanese, Garland, Gipson, & Blackmon, 2000). There is increasing interest in the quality of care provided to older adults, and evidence suggests that delivery of good nursing care in LTC facilities is reflected in nurses' descriptions of factors and structures that affect their work (Tuckett et al., 2009). Understanding this contemporary nature of nursing work in LTC has a strong influence in outlining policies for improving current system use in LTC facilities (Jones et al., 2002). However, limited evidence suggests there is a constrained understanding of how nurses function in LTC settings.

With the growing demand for LTC services, which is sensitive to the aging population, it is timely to gather available evidence to synthesize an informed perspective of nursing work processes occurring in LTC settings. To synthesize a novel understanding of nursing work in LTC, an integrative review approach was considered the most appropriate method in achieving the aim of the current review.

Review Objectives

The aim of the current review is to present a contemporary perspective of RNs' work in LTC facilities. The review is guided by the following inquiries: (a) what specific tasks or activities do RNs manage in LTC facilities?; and (b) what is the defining characteristic of RNs' role in LTC facilities?

Method

An integrative review methodology allows the inclusion of diverse methodologies to achieve a more comprehensive understanding by synthesizing new knowledge on a particular topic of interest (Whittemore & Knafl, 2005). Due to limited studies on RN work in LTC, an integrative review method develops a more holistic perspective from the available research through an organized review process. Steps included problem identification, literature search, data evaluation, data analysis (i.e., reduction, display, comparison, conclusion drawing, and verification), and presentation of synthesized understanding and its implication for practice (Whittemore & Knafl, 2005). As part of the data evaluation step, a quality appraisal process was undertaken for the studies selected for review (Pluye et al., 2011).

Search Strategy

A comprehensive search of the literature was conducted using the CINAHL, PubMed, Medline, Scopus, and Google Scholar electronic databases with the following search terms: “nursing work, nursing activities, nursing tasks” AND “registered nurse, nurses, aged care staff” AND “aged care,” and synonymous terms such as “residential care, LTC” AND/OR “nursing homes.” The keywords “nursing role and work patterns” were also searched as an equivalent and commonly substituted term for “work.” Limiters were applied, which narrowed the search according to the inclusion and exclusion criteria. Inclusion criteria were: original empirical studies with diverse methodologies, publication in a peer-reviewed academic journal, focused on RNs' work (specifying nursing tasks and activities in aged care), and full-text articles published between 2000 and early 2016 in English or with retrievable English versions. Exclusion criteria were: data synthesizing reviews, editorial articles, and discussion papers; publication in a non–peer-reviewed journal; studies involving multidisciplinary teams that did not clearly present specific RN data components in LTC; studies published before the start of the 21st century; and studies with a pre-selected focus on a specific RN nursing task or activity.

Exclusiveness of the publication period is crucial to capturing a contemporary perspective of RN work in aged care; therefore, studies selected for the review were published from 2000–2016. Search aides through Boolean operators and truncated terms (e.g., nurs* and aged car*) were also applied for database searching. To counter terminology and indexing limitations, additional search methods were used (Whittemore & Knafl, 2005) via an ancestry search for potential studies eligible for inclusion from the articles' reference lists.

PRISMA Screening and Quality Appraisal

The initial literature search was conducted in September 2015 and repeated in April 2016. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework (Moher, Liberati, Tetzlaff, & Altman, 2009) was used in this screening process (Figure). A total of 2,129 articles were found using the combination of search terms with limiters applied. Following the PRISMA framework, nine studies satisfied the screening process with specific reference to the outlined inclusion/exclusion criteria.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of study selection process.

Figure.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of study selection process.

The nine studies were examined using Pluye et al. 's (2011) Mixed Method Appraisal Tool. The tool was modified with permission by using only the applicable aspects of the tool in checking the quality of the methodologies used in the studies (Table A, available in the online version of this article). A section addressing ethical conduct of research was also added. The tool provided a uniform, single-format quality appraisal process of the methodologically diverse studies.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Data Abstraction and Synthesis

All nine articles were carefully read and data synthesis was conducted using integrative methodology steps by Whittemore and Knafl (2005). Data were grouped according to type of evidence, research design, settings, and sample characteristics, and then inductively coded. After synthesizing useful data, a concept map was created (data display). The interrelated conceptual data were then compared and contrasted in an iterative process (data comparison) and then regrouped to similar concepts or themes. A pattern was then identified for similarities and differences needed in drawing conclusions.

Results

Study Characteristics

The studies reviewed (Table 1) used varied methodologies with quantitative, qualitative, and mixed-method approaches. Five studies used a quantitative approach (Dellefield, Harrington, & Kelly, 2012; Hall & O'Brien-Pallas, 2000; McCloskey, Donovan, Stewart, & Donovan, 2015; Munyisia, Yu, & Hailey, 2012; Paquay et al., 2007). Four of these studies used work sampling and direct observation methods, as well as researcher-developed instruments (Dellefield et al., 2012; Hall & O'Brien-Pallas, 2000; McCloskey et al., 2015; Munyisia et al., 2012). Only Paquay et al. (2007) used a quantitative self-report form to record RN activities. Three studies used qualitative approaches (Bedin, Droz-Mendelzweig, & Chappuis, 2012; McGilton, Bowers, McKenzie-Green, Boscart, & Brown, 2009; Perry, Carpenter, Challis, & Hope, 2003). These approaches used varied methodologies, including exploratory qualitative design and grounded theory. Only one study (Hunter & Levett-Jones, 2010) used a mixed-method design examining RN work in LTC through questionnaires and semi-structured interviews. Study samples ranged from nine (Perry et al., 2003) to 117 (McCloskey et al., 2015) RNs. The studies were conducted in the following regions: United States (n = 1), Canada (n = 3), Australia (n = 2), United Kingdom (n = 1), Belgium (n = 1), and Switzerland (n = 1). Emerging themes revealed that nursing work in aged care settings is characterized by RNs providing indirect care tasks—primarily care coordination, non-nursing activities, and expanded and overlapping roles (Table 2).

Summary of Reviewed StudiesSummary of Reviewed Studies

Table 1:

Summary of Reviewed Studies

Nursing Work in Long-Term Care (LTC)

Table 2:

Nursing Work in Long-Term Care (LTC)

Indirect Care Tasks

Care Coordination. All studies reviewed categorized tasks in LTC facilities as direct, indirect, and non–value-added or non-nursing tasks. RNs were primarily indirect care providers, providing a broad range of activities essential to the health and well-being of older adults, but did not necessarily personally provide such care activities. Indirect care tasks performed by RNs in LTC included planning and coordinating care provided by other staff (Bedin et al., 2012; Hall & O'Brien-Pallas, 2000; Hunter & Levett-Jones, 2010); acting as administrator, manager, supervisor, coordinator, or surveillance person (Dellefield et al., 2012; McGilton et al., 2009; Perry et al., 2003;); overseeing practical nursing procedures; acting as liaison for administrative tasks (Hunter & Levett-Jones, 2010; Paquay et al. 2007); and overseeing medication management, documentation, and chart reviews (Dellefield et al., 2012, McCloskey et al., 2015; Munyisia et al., 2011).

Direct care tasks commonly identified included providing treatment, respiratory support, or medication administration (Hall & O'Brien-Pallas, 2000; Munyisia et al., 2011; Paquay et al., 2007), and were considered one of the mainstay components of RNs' multiple responsibilities in LTC (McGilton et al., 2009). Time spent on indirect nursing tasks were considered crucial to the overall operation in a nursing work shift, and mostly focused on close surveillance of direct care activities provided by other staff members.

Non-Nursing Activities. In relation to perceived uncertainty in defining RN role boundaries in LTC and the increasing sense of taking accountability for care provided by others (Perry et al., 2003), few studies found that RNs engage in activities beyond their work boundaries (i.e., non-nursing tasks [Hall & O'Brien-Pallas, 2000], non-clinical tasks [McGilton et al., 2009], or non–value-added activities [McCloskey et al., 2015]). Although terminologies differ, these activities refer to tasks beyond the expectations of RNs' scope of work, which may contribute to the holistic delivery of older adults' care. These activities are normally undertaken and expected from other staff, such as health care assistants, receptionists, clerks, security personnel, and marketing and other administrative staff (Hall & O'Brien-Pallas, 2000; McCloskey et al., 2015; McGilton et al., 2009). Hall and O'Brien-Pallas (2000) noted that RNs in LTC are the second most identified staff members spending a lot of time on non-nursing care activities. Most studies underscored that overlapping work roles and scopes occur, as evidenced by RNs engaging in the work of other less qualified staff due to poor delegation and unclear work roles (Paquay et al., 2007; Perry et al., 2003). Hunter and Levett-Jones (2010) described the managerial aspects of RNs' roles in LTC, which are not limited to floor or shift management but also a whole facility level. RNs are involved in some planning activities in LTC, which are considered not directly related to care but contribute to care delivery (Hunter & Levett-Jones, 2010). Similarly, Bedin et al. (2012) emphasized that this major managerial workload of nurses in managing material and human resources confines nurses' activities to office work. Such activities include “doing inventories, managing stocks, placing orders, preparing administrative forms, scheduling and doing personnel evaluation” (Bedin et al., 2012, p. 114). These types of tasks were also noted by McCloskey et al. (2015) as non–value-added activities, including “restocking, searching for equipment and supplies, distributing linens and looking for other care providers” (p. 1478).

Expanded and Overlapping Roles. The third theme describes the RN work role boundaries in LTC facilities. Perry et al. (2003) noted that RNs working in nursing homes find it difficult to specifically define their role and work. Therefore, LTC RNs are said to assume an “all embracing role, doing everything and anything within the nursing home” (Perry et al. 2003, p. 500). RNs in LTC facilities have multiple responsibilities while also filling gaps in unfinished clinical tasks or catering responsibilities beyond clinical work (McGilton et al., 2009). RNs normally working on the floor also incurred expanded roles and new work appointments (e.g., infection control nurse, continence nurse), causing an expansion of roles and additional work responsibilities (Hunter & Levett-Jones, 2010). This extension is increasing the ambiguity in specifically defining nursing work in terms of the scope of RNs' work and what they are expected to do in LTC (McGilton et al., 2009; Perry et al. 2003).

Discussion

The current integrative review presents a contemporary understanding of RN work in LTC settings, identifying specific RN tasks and activities while providing a holistic description of RNs' role in LTC. Nursing work in LTC facilities was identified as focused on delivering indirect care activities to older adults, which are best described as resident-related care tasks but do not necessarily require RNs to be physically present or directly providing care. However, this finding was the opposite of that in previous studies on nursing work in acute care settings, in which nurses mostly provided direct care activities and were also involved in other non-technical activities (Chaboyer et al., 2008; Farquharson et al., 2013). Despite this reference to LTC RNs having lesser involvement in providing direct care to residents, RNs acknowledge and value the provision of direct care more than other staff members in LTC settings (Hall & O'Brien-Pallas, 2000).

Aside from administration of medications, care planning, and monitoring treatments, care coordination is the common and primary responsibility of RNs in LTC. Care coordination was undertaken through supervision of direct care activities provided by other staff members, such as hygiene care and assisting with meals, showering, toileting, and other activities of daily living. This care coordination role was consistently identified in the reviewed studies, introducing a clear perspective of RN activities specific to LTC. The role of RNs as indirect care providers in LTC settings confirms research findings of less qualified staff acting as primary providers of essential care activities for older adults (Mallidou, Cummings, Schalm, & Estabrooks, 2013; Qian et al., 2012). Furthermore, looking at the specific tasks RNs perform in LTC provokes thinking about the activities that can be successfully completed by other staff members with or without RN surveillance (Duffield et al., 2008; Schirm et al., 2000). The current nursing work structure resonates with anecdotal reports on LTC facilities having unregulated staff administer medications and dress wounds, as studies have suggested that RNs confine themselves to indirect care coordination activities. These care coordination roles and monitoring functions of RNs define gerontological nursing in LTC facilities.

To coordinate and monitor care provided by others entails a complex, broad range of activities that go beyond technical nursing skills (Carlson, Rämgård, Bolmsjö, & Bengtsson, 2014). The current work structure in LTC settings suggests that RNs should be familiar with other staff members' tasks and be ready to step in when the situation requires. This broad coverage of RN work as coordinators of care led to the notion of all-embracing care with unclear work boundaries, causing overlapping roles among other aged care staff (Suter et al., 2014). The literature has identified nurses engaged in ambiguous activities beyond their job description or work scope (Pearson, 2003). Duffield et al. (2008) noted this engagement had no direct therapeutic value. These activities were recognized as non-nursing tasks. Such activities are perceived to erode the professional status of nurses and undermine nursing skills and expertise (Duffield et al., 2008; Hayes, 2000).

In LTC, nurse staffing was a predictor of the quality of care provided to older adults (Spilsbury, Hewitt, Stirk, & Bowman, 2011). However, the current review provided another angle for a potential quality indicator in LTC settings. There is increased ambiguity in defining the nursing role (Pearson, 2003), as supported by evidence revealing the concept of interchangeability of RN work roles with other less qualified staff (Corazzini et al., 2013). Expanded and overlapping RN roles decrease residents' awareness in recognizing RNs' responsibilities (Jones et al., 2002). The interchangeability of RN roles is due to lack of clarity and definite boundaries between other staff in LTC facilities, which fosters confusion and challenges role accountability (White et al., 2015). Non-nursing tasks or non–value-added activities (Upenieks, Akhavan, & Kotlerman, 2008) are increasingly identified in the acute care literature and occupy most RNs' time in LTC.

Limitations

The current review has several limitations, particularly the limited amount of studies found on nursing work in LTC. Although a comprehensive search was conducted and potential relevant articles were initially retrieved, inclusion and exclusion criteria strictly narrowed the selection for eligible studies. Another limitation was the quality of the articles included (e.g., low sampling sizes, unclear mention of the sampling process). Most studies were observational, which may have reliability issues regarding recording behavior while being observed or the Hawthorne effect. In addition, social desirability biases may influence RNs' participation in the research. Another limitation was the varying organizational structures (e.g., staffing) in LTC in the different countries and settings.

Practice Implications and Future Research

RNs' work and roles in LTC require further research exploring nursing- and non–nursing-related tasks across different settings (e.g., assisted living, continuing care, hospital or residential level of care, special dementia care units) in the LTC services structure. Although RNs in aged care provide less direct care and act as coordinators of care for resident-related care and non–resident-related activities, this trend calls for clarifying work roles between RNs and other staff to ensure quality and safe nursing care is being provided. Furthermore, examination is needed of the degree of interchangeability of work roles and patterns between RNs and other staff in aged care, while looking at the safety and quality threshold of having RN-specific tasks delegated to less qualified staff or ancillary staff and vice versa. The increasing acuity compounded by the presence of multiple comorbidities among LTC service users suggests strengthening of RNs' education and preparation for LTC nursing is needed. With the current challenge of recruiting nurses in LTC, it is timely to promote a career in LTC nursing by incorporating specific RN LTC roles in curricula.

Conclusion

The complex natures of RNs' tasks and work roles in LTC are potential indicators for redesigning nursing work structures in the LTC setting. RNs as care providers in LTC do not always provide direct care as part of their nursing work and may instead act as coordinators of care provided by others. The scope of RN work stretching beyond its clinical nature, such as undertaking non-nursing tasks, adds complexity in clarifying RN work roles.

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Summary of Reviewed Studies

Author (Year), Country Purpose Method Sample Major Findings (Specific to RNs)
Hall & O'Brien-Pallas (2000), Canada To determine perceived job characteristics of staff who perform nursing and ancillary nursing care activities in long-term care (LTC) Quantitative, observational, work sampling approach 46 RNs and ancillary staff in two LTC nursing units <list-item>

RNs spent the most time performing indirect care activities.

</list-item><list-item>

RNs valued the provision of direct care but performed the lowest percentage of direct care activities.

</list-item><list-item>

RNs were second most identified staff members spending time performing non-nursing care activities.

</list-item>
Perry, Carpenter, Challis, & Hope(2003), United Kingdom To obtain an in-depth understanding of the main differences between roles and functions of registered general nurses (RGNs) and care assistants in nursing homes Qualitative, exploratory, semistructured interviews Nine RGNs and 12 care assistants in four nursing homes <list-item>

RGNs perceived that they assume an all-embracing role, doing everything and anything in the nursing home.

</list-item><list-item>

RGNs' sense of accountability and lack of clear role directives made them engage in work normally done by care assistants and posed ineffective delegation.

</list-item>
Paquay et al. (2007), Belgium To examine the care tasks performed by RNs and care assistants in nursing homes Quantitative, comparative design, Belgian activities of daily living evaluation scale 26 aged care institutions <list-item>

No significant difference between total time spent by RNs and care assistants with resident-related tasks.

</list-item><list-item>

RNs spent significantly more time than care assistants in practical nursing procedures and communication and administrative tasks.

</list-item><list-item>

RNs had trouble delegating primary care, logistic, and supportive tasks to other staff.

</list-item>
McGilton, Bowers, McKenzie-Green, Boscart, & Brown (2009), Canada To explore RNs' understanding of their role as charge nurses in LTC Qualitative, grounded theory (dimensional analysis) 16 RNs from eight LTC facilities <list-item>

RNs attended multiple responsibilities and developed strategies to compensate workload.

</list-item><list-item>

RNs filled gaps in unfinished clinical work (previous shift) and responsibilities beyond clinical work.

</list-item><list-item>

Nurses multi-tasked due to organizational and time constraints and unpredictable interruptions.

</list-item>
Hunter & Levett-Jones (2009), Australia To provide a description of the practice of nurses caring for older adults in LTC Mixed method, questionnaires, document sources, semistructured interviews 48 clinical RNs and 16 nurse managers from six acute LTC facilities <list-item>

RNs' role fell within a specialized context.

</list-item><list-item>

RN activities identified in more than 50% of nursing homes were tasks involving care coordination and administrative activities.

</list-item><list-item>

RNs increasingly performed managerial and supervisory roles, as well as other expanded roles.

</list-item>
Munyisia, Yu, & Hailey (2011), Australia To examine how nursing staff spend their time on nursing activities Quantitative, observational, work sampling approach 13 RNs, four EENs, 52 PCs, and six RAOs from two units in a 110-bed nursing home RNs spent most of their time liaising with families, organizing resident medical appointments, and talking to other members of the health team, followed by medication management and documentation. Only 7.7% of nurses' time was allocated for direct care.
Dellefield, Harrington, & Kelly (2012), United States To describe direct and indirect care distribution of RNs during a shift in a nursing home Quantitative, work sampling approach, RNOM RNs, LVNs, and CNAs in 174-bed nursing home RNs spent most of their clinical time performing indirect care.
Bedin, Droz-Mendelzweig, & Chappuis (2012), Switzerland To explore the daily experience of work in nursing homes focusing on RNs' role Qualitative, semistructured interviews RNs forming 18 FGDs from nine LTC nursing homes RNs primarily performed coordination activities.
McCloskey, Donovan, Stewart, & Donovan (2015), Canada To explore and identify variations of the activities of care providers in different nursing homes Quantitative, cross-sectional, observational 117 RNs, 196 LPNs, 402 RAs from seven nursing homes <list-item>

RNs spent less time providing direct care and more time engaged in indirect care activities.

</list-item><list-item>

RNs spent 14.7% of their time on non–value-added tasks.

</list-item>

Nursing Work in Long-Term Care (LTC)

Nursing Activities RNs Perform in LTC
Indirect care tasks (care coordination activities)
  • Planning and coordinating care provided by others
  • Administrator, manager, supervisor, coordinator, and surveillance roles
  • Supervising practical nursing procedures, acting as liaison for administrative tasks
  • Medication management, documentation, and chart reviews
Non-nursing activities
  • Performing jobs expected among health care assistants, receptionists, clerks, security personnel, marketing, and other administrative staff
  • Managing material and human resources
  • Managing inventories, managing stocks, placing orders, preparing administrative forms, and scheduling and conducting personnel evaluations
  • Restocking, finding equipment and supplies, distributing linens, and finding other care providers
Expanded roles
  • New work appointments (e.g., infection control nurse, continence nurse)
  • Overlapping work scopes with other staff members
Authors

Dr. Montayre is Lecturer in Nursing, and Ms. Montayre is Clinical Educator in Nursing (Gerontology), School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jed Montayre, PhD, RN, Lecturer in Nursing, School of Clinical Sciences, Auckland University of Technology, 90 Akoranga Drive, Northcote, Auckland 0627, New Zealand; e-mail: jed.montayre@aut.ac.nz.

Received: December 16, 2016
Accepted: April 24, 2017
Posted Online: May 30, 2017

10.3928/00989134-20170519-02

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