Journal of Gerontological Nursing

Feature Article 

Fall Prevention Among Community-Dwelling Older Adults: Current Guidelines and Older Adult Responses

Helen W. Lach, PhD, RN, CNL, FGSA, FAAN; Wanida Noimontree, PhD, RN, GNC

Abstract

Older adults are vulnerable to falls that result in injury and disability, making fall prevention a national priority. The purpose of the current study was to evaluate community-dwelling older adults' perceptions about falls and fall prevention activities to guide interventions. Participants had high awareness of falls and believed that they could reduce their risk of falling. Approximately three fourths of participants reported taking actions to reduce risk of falling; however, participation in community fall prevention programs was low. The survey used provides a method to help nurses identify targets for fall prevention interventions to reduce this physical health disparity in vulnerable older populations. [Journal of Gerontological Nursing, 44(9), 21–29.]

Abstract

Older adults are vulnerable to falls that result in injury and disability, making fall prevention a national priority. The purpose of the current study was to evaluate community-dwelling older adults' perceptions about falls and fall prevention activities to guide interventions. Participants had high awareness of falls and believed that they could reduce their risk of falling. Approximately three fourths of participants reported taking actions to reduce risk of falling; however, participation in community fall prevention programs was low. The survey used provides a method to help nurses identify targets for fall prevention interventions to reduce this physical health disparity in vulnerable older populations. [Journal of Gerontological Nursing, 44(9), 21–29.]

Falls are a leading cause of morbidity and mortality among community-dwelling older adults worldwide (World Health Organization, 2007), affecting approximately one third of older adults each year (Centers for Disease Control and Prevention [CDC], 2017). Physical and psychological outcomes of falls can lead to a decline in function, loss of independence, and premature death, and result in increasing costs to health care systems (Burns, Stevens, & Lee, 2016; DeGrauw, Annest, Stevens, Xu, & Coronado, 2016). As a result, fall prevention is a national priority, and included in the goals of Healthy People 2020 (Healthy People, 2018).

After several decades of research, researchers have identified evidence-based fall prevention interventions, supported by guidelines, systematic reviews, and meta-analyses. Unfortunately, few older adults participate in or adhere to fall prevention activities in the community, and providers may not address falls (Child et al., 2012; Phelan, Aerts, Dowler, Eckstron, & Casey, 2016; Yardley et al., 2007). Understanding older adults' perceptions is important to address this critical public health problem. In the current article, researchers discuss fall prevention guidelines and present data from older adults participating in a community survey along with implications for practice.

Researchers have provided strong evidence for numerous fall prevention interventions for community-dwelling older adults. In systematic reviews and meta-analyses, various individual or combined interventions to reduce falls have been examined. Researchers have found that multifocal programs (e.g., home safety evaluations and modification with exercise, education, medication reviews, visual checks, or use of assistive devices) reduce fall rates (Chase, Mann, Wasek, & Arbesman, 2012; Gillespie et al., 2012, Tricco et al., 2017). Home safety evaluation and environmental modification are effective interventions to reduce falls (Clemson, Mackenzie, Ballinger, Close, & Cumming, 2008; Gillespie et al., 2012). Exercise, especially when balance training is included, reduces falls, either as a single intervention or combined with other interventions (Gillespie et al., 2012; Hempel et al., 2014; Robertson, Campbell, Gardner, & Devlin, 2002; Sherrington et al., 2017; Tricco et al., 2017).

For health care providers, guidelines for fall prevention and an algorithm are available from the Panel on Prevention of Falls in Older Persons, American Geriatrics Society, and British Geriatrics Society (2011). The U.S. Preventive Services Task Force (2018) has newly updated guidelines. The CDC (2017) developed the Stopping Elderly Accidents Deaths and Injuries (STEADI) initiative, offering fall prevention materials and resources for health care providers and older adults. The National Council on Aging (NCOA; n.d.b) developed a National Fall Prevention Action Plan, along with support for providers through the Falls Free Initiative with national and state fall prevention coalitions and an annual Fall Prevention Awareness Day. Nurses should be aware of evidence-based interventions for falls, and a list of recommendations is provided in Table 1.

Summary of Evidence-Based Fall and Injury Prevention Interventions

Table 1:

Summary of Evidence-Based Fall and Injury Prevention Interventions

To understand more about older adults' responses to the recommendations and interventions for fall prevention, the current researchers surveyed older adults across a large metropolitan area. The aims were to identify older adults' self-reported attitudes, beliefs, and actions related to falls. Researchers also explored factors affecting these perceptions.

Method

After obtaining Institutional Review Board approval, the fall survey was administered to older adults at 16 sites across a large Midwestern metropolitan area. Participants were recruited from senior centers, health fairs, fall screening events, educational classes, and exercise programs. Sites were primarily urban and suburban; one site included rural participants. Participants were given a recruitment statement and verbal description of the study, and completion of the questionnaire implied consent to participate. Researchers conducted a raffle for a $10 gift card as incentive. Surveys were anonymous and names submitted on separate papers for raffle drawings, which were destroyed after gift cards were distributed at each site.

Measures

The survey contained three parts. The first part addressed participants' demographic information including age, gender, educational level, race, history of chronic conditions, mental and physical functioning, and history of health care use. Questions were included to ascertain falls and injury history. In addition, two scales were included to evaluate concerns about falling.

Participants were asked if they were fearful or concerned that they might fall or lose their balance. If they responded yes, they rated their concern from 1 to 10, with 10 indicating very concerned. The mean score was six, which was used as the cutoff for comparisons, with higher scores indicating greater concern about falling. The Short Falls Efficacy Scale-International (Short FES-I; Kempen et al., 2008) examines falls self-efficacy, or the concern an individual has about falling during routine daily activities, such as taking a shower or bath or going to a social event. Responses included four choices, from not at all concerned to very concerned, with total scores ranging from 7 to 28. The recommended cutoff score of ≥11 indicates poorer falls self-efficacy or higher concern (Delbaere et al., 2010). The short FES-I has good psychometric properties, including good 4-week test–retest reliability (intraclass correlation coefficient = 0.83), Cronbach's alpha of 0.92, and a correlation with the FES-I of 0.97 (Kempen et al., 2008).

Questions regarding perceptions of falls were drawn from a survey for older adults developed by an expert panel to help state fall prevention coalitions monitor the older adult population (NCOA, n.d.c). The survey addressed three concepts related to fall prevention: awareness of falls, beliefs about ability to prevent falls, and actions taken to prevent falls. Two questions were designed to examine salience, or awareness of falls. One question from Howland et al. (1993) asked respondents to rate their concern about falls compared to four other potential risks, including serious illness, being victim of a crime, financial concerns, or forgetting something important. In another question, respondents rated the priority of fall prevention for older adults on a scale of 1 to 10. The purpose of these questions was to determine how important older adults consider falls and fall prevention.

To explore beliefs about fall prevention, the survey included a question about falls being preventable. Participants rated their agreement with the statement “I can do things to reduce my chances of falling.” Five response choices were given, from strongly agree to strongly disagree. To evaluate behaviors and activities, respondents were then asked to identify what they had done to reduce their chance of falling from a checklist of recommended actions drawn from fall prevention guidelines (NCOA, n.d.c). Items included: talked to a family member or friend about how to reduce risk of falling, talked to a health care provider about how to reduce risk of falling, participated in a community fall prevention program, had a vision check, had medications reviewed by a health care provider or pharmacist, or made changes in the home. A separate question asked about exercise participation and frequency.

Analysis

Descriptive statistics were used to analyze characteristics of the sample and responses to evaluation questions. Participant characteristics were compared based on participants' history of falls. Further, responses on the survey questions were compared based on factors associated with falling, including chronic conditions, history of falls, fear of/concern about falling rating, and scores on the Short FES-I. Independent samples t tests were used to compare continuous variables, and chi-square tests were used to compare dichotomous variables. Data analyses were performed using SPSS version 22.

Results

A total of 267 older adults with various demographics completed the survey (Table 2). Most participants were women (81.4%) and White (81.7%), with a mean age of 75 years (range = 53 to 94 years, SD = 9.1 years) and a mean education length of 14.5 years (range = 4 to 22 years, SD = 3 years). Older adults reported having several chronic conditions (mean = 4.3 chronic conditions, SD = 2.6 chronic conditions, range = 0 to 17 chronic conditions) and medications (mean = 4.5 medications, range = 0 to 11 medications, SD = 3.5 medications). Participants had an average of 2.6 (range = 0 to 12, SD = 2.4) physician visits in the past 6 months. Participants who experienced a fall had significantly more chronic conditions, higher prevalence of falling, higher rating of fear of/concern about falling, and higher scores on the Short FES-I, and were more likely to use a walking aid than participants who had not experienced a fall. Although 20.9% of participants reported an injury from a fall, most were minor and only 2.7% resulted in an injury requiring hospitalization.

Demographic Profile of Older Adult Survey Participants by History of Falls

Table 2:

Demographic Profile of Older Adult Survey Participants by History of Falls

Awareness, Beliefs, and Actions to Prevent Risk of Falling

Respondents had good awareness of the importance of falls, with more than one half rating falls as one of their highest concerns when compared to serious illness, being victim of a crime, financial concerns, or forgetting something important (Table 3). When asked to rate the importance of taking steps to reduce their risk of falling (categorized as awareness of falls), the mean was high at 9.1 (SD = 1.7, range = 1 to 10). Furthermore, most participants (94%) agreed that they could reduce their risks of falling (categorized as beliefs about ability to prevent falls).

Older Adults' Awareness of, Beliefs about, and Actions to Reduce Risk of Falling

Table 3:

Older Adults' Awareness of, Beliefs about, and Actions to Reduce Risk of Falling

Regarding actions taken to prevent falls, most (70.9%) participants reported being active in some fall prevention activities, with 11.1% taking four or more actions to prevent a fall. To reduce risk of falling, 45.1% of participants made changes in their homes and 41.4% had their vision checked. However, only 19.8% of participants reported talking with their health care provider about how they could reduce their risk of falling, and only 17.3% talked to family members or friends about falls. Approximately one fourth of respondents had their medications reviewed.

Few (13.9%) older adults had participated in a community fall prevention program in the past 1 year. However, 83.3% of older adults reported exercising in the past 3 months and approximately one half (57.9%) believed that exercise programs help improve their fitness. Of those who exercised, 51.3% reported exercising for ≥30 minutes at least two times per week. Researchers found that 24.7% of participants had used a home safety checklist to evaluate their home, but 42.2% of participants had never even seen one. Overall, 22.1% of older adults had not taken any actions to reduce risk of falling.

Researchers explored the influence of falls and fear of/concern about falling on participants' awareness of falls and beliefs about their ability to prevent falls. Based on fall history, there were no significant differences in awareness or beliefs (Table 3). Participants who had fallen were more likely to have taken action to prevent a fall, although not all actions were significantly different based on fall history. More individuals who had fallen talked about falls to a family member or friend (χ2 [1, N = 267] = 6.1, p = 0.014) or their health care provider (χ2 [1, N = 267] = 5.8, p = 0.016), or made changes in their home (χ2 [1, N = 267] = 6.5, p = 0.010) than non-fallers.

Participants with fear of/concern about falling scores >6 (t [229] = −3.21, p = 0.002) were more likely to have talked to a health care provider about falling. A similar pattern was seen in individuals with higher concern about falling or poor falls self-efficacy scores on the FES-I (>14.8 [range = 7 to 28, with higher scores indicating greater concern about falling]; t [207] = −4.09, p < 0.001). Participants with higher concern were also more likely to have talked with family members or friends about reducing falls (t [207] = −4.372, p < 0.001). Participants who exercised had lower ratings of concern about falling (mean = 4.2, SD = 3.9) than participants who did not exercise (mean = 5.6, SD = 3.9) (t [211] = 2.22, p = 0.028).

Discussion

The current study provides important findings that can help nurses address fall prevention in community-dwelling older adults. Older adults are concerned about falls and think fall prevention should be a priority. Participants' generally high awareness of falls and beliefs that they could reduce the risk of falls were positive findings, as the fall prevention coalition in Missouri had conducted widespread fall awareness activities in the geographic region over the past 8 years. In a prior review, researchers found older adults' perceptions of fall risk were related to feelings of vulnerability and desire to maintain independence (McMahon, Talley, & Wyman, 2011). Furthermore, researchers noted that older adults who had fallen acknowledged their individual risks, whereas those who had not experienced a fall did not always feel risks were personally relevant. The current researchers found that individuals who had fallen were more likely to have taken actions to prevent falls, although this finding was not statistically significant. Falls may increase awareness of vulnerability and can increase fear of falling, providing a teachable moment in which health care providers can encourage more fall prevention activities.

However, in a study by Verghese (2016), researchers found low fall risk awareness among ambulatory community-dwelling older adults. Continued fall awareness and educational activities are recommended to help older adults develop realistic awareness of falls and identify individual fall risks that support their taking actions to prevent falls while discouraging development of fear of falling. Ongoing attention to fall prevention is particularly important for the population surveyed in the current study, as researchers at the CDC found fall rates in Missouri to be higher than fall rates in most states (Bergen, Stevens, & Burns, 2016), and fall rates remain high in most of the country.

Less than 20% of participants said they had talked to their health care provider or a family member or friend about reducing risk of falling. Older adults may have barriers to bringing up falls or concerns about falling (Lach, Krampe, & Phongphanngam, 2011), such as fear of interventions limiting their independence. Health providers need to be proactive and ask about falls, evaluate fall risk factors, and make recommendations for patients to help them reduce their risks. Studies show that asking about falls is not routine practice for most providers, even in high-risk patients (Phelan et al., 2016). The current survey did not explore details of what providers or families discussed or what resulted from those discussions. More information about interactions with providers might help inform ways to ensure that falls are discussed and evidence-based interventions are recommended.

The sample for the current study was more active than expected in some areas of fall prevention, such as exercise, with approximately one half of participants reporting regular exercise. Falls and fear of falling often result in reduced activity and less participation in exercise. Older adults, family members, and even some providers may have misconceptions that reduced activity will keep older adults safe. These concerns are prevalent in other settings as well, including hospitals (Growdon, Shorr, & Inouye, 2017) and nursing homes (Resnick, Galik, Gruber-Baldini, & Zimmerman, 2012). However, exercise is consistently a strong intervention for fall prevention (Tricco et al., 2017), and some studies show reduced injuries from falls in individuals who are more active (Karinkanta, Kannus, Uusi-Rasi, Heinonen, & Sievänen, 2015).

The number of individuals who exercised in the current study was higher than numbers in other reports in the literature. Numerous barriers to exercise have been identified. Only approximately 20% of U.S. adults meet overall physical activity recommendations by the American College of Sports Medicine (Garber et al., 2011). Higher numbers in the current study may be related to recruitment strategy for the survey. Many participants were recruited from health and educational events, which may attract older adults interested in health promoting behaviors, and some participants were recruited from exercise classes. In addition, lack of a definition of exercise, such as the definition provided by the American College of Sports Medicine (Garber et al., 2011), may have resulted in over-reporting of exercise, as some individuals consider any kind of physical activity to be the equivalent of exercise for fitness. However, participants had a wide range of ages, health, and educational levels, and approximately one fifth of participants reported not exercising.

Only approximately one fourth of participants said they had their medications reviewed by a provider or pharmacist, although reviewing may have occurred without patient awareness. In addition, although a provider may have reviewed a patient's medications, they may or may not have considered fall risk in this process. In the presence of a fall or fall risks, potential impact of medications should be reviewed.

It was surprising that approximately one half of participants reported never seeing a home safety checklist, although many had made changes in their homes to prevent a fall. There are numerous versions of such tools available in print and online, and it was anticipated that more of the sample would be familiar with these tools. In a review of checklists, Kercher and Rubenstein (2003) found many examples with commonalities among different tools, but also some variations in readability, and whether recommendations for addressing risks were noted. In the past, researchers found older adults who had used a home safety checklist were more likely to have made safety changes in their homes (Clemson et al., 2008; Tomita, Saharan, Rajendran, Nochajski, & Schweitzer, 2014). Older adults often enjoy collecting handouts at health fairs and activities, but may not later read the materials. Thus, continued efforts to give out checklists are needed, but should be accompanied by education on their importance and how to use them to prevent individuals from throwing them away.

An important concern regarding findings from the current survey was the low participation rate in fall prevention programs. The low rate was not surprising given that few programs are available in most communities. Several evidence-based programs have been tested and have been shown to reduce falls or fall risk factors, and in a cost–benefit analysis, a positive return on investment was shown (Carande-Kulis, Stevens, Florence, Beattie, & Arias, 2015). For example, the group programs Stepping On (Mahoney, 2014) and A Matter of Balance (MaineHealth, 2017), and exercise programs such as Tai Chi Moving for Better Balance (Oregon Health Authority, n.d.) or Otago for homebound elders (Shubert, Smith, Jiang, & Ory, 2018), are tested programs with good outcomes. Additional programs have been reviewed by the NCOA (n.d.a) and approved as evidence-based fall prevention programs and are posted on their website (access https://www.ncoa.org/healthy-aging/falls-prevention/falls-prevention-programs-for-older-adults). These programs are packaged and available for dissemination.

Despite available options, providing health promotion programming is a common challenge across many communities (Altpeter, Schneider, & Whitelaw, 2014). Availability of trained facilitators, lack of awareness about fall prevention, and costs may limit community organizations from offering evidence-based fall prevention programs. Resources are increasing with awareness of the public health impact of falls. For example, the Administration for Community Living provides grants to help communities build capacity to provide these programs. Further, methods to increase funding for such programs, including insurance reimbursement, are being explored. These initiatives may gradually result in changes that can be tracked using the NCOA evaluation survey.

Three fourths of current participants reported taking at least one action to reduce their chance of falling. The NCOA evaluation question about actions to prevent falls was also used in the Behavioral Risk Factor Surveillance Survey by the New York State Department of Health, which found that 42.5% and 41.9% of respondents ages ≥65 reported doing something to prevent a fall in 2012 and 2014, respectively (Bauer & Garnett, 2016). However, the Behavioral Risk Factor Surveillance Survey did not provide a list of options for fall prevention actions, as in the current survey, but simply asked as a yes/no question. The current list may have led to increased responses. The New York findings are likely more generalizable to the broad population of older adults than the current findings, as the survey was population-based rather than a convenience sample. Continued efforts are needed to increase older adults' taking actions related to fall prevention.

Limitations

The current study was limited in that a convenience sample in one metropolitan area was surveyed. However, the NCOA fall evaluation questions provided a useful profile of fall awareness, beliefs about ability to prevent falls, and actions taken to prevent falls among older adults in a Midwest metropolitan community. Older adults answered survey questions and used the full range of responses on each question, indicating survey items could identify individual variations for questions. Researchers could see influences of having fallen and fear of falling on most responses, in expected directions, providing some support for validity of the questions, although not all comparisons were significant. Fall prevention coalitions can use these survey questions to identify older adults' attitudes about falls and actions to address falls in their communities. As it was a brief survey, survey questions did not explore specific barriers to or facilitators of acting to prevent falls. More detail about these factors or local influences could be collected with added survey questions, supplemental interviews, or focus groups.

Conclusion

Fall prevention continues to be an important goal. Nurses in many settings touch older adults' lives. They can assess older adults for fall risks and recommend evidence-based interventions. Nurses can join with state and local fall prevention coalitions to educate others and conduct ongoing evaluation of these efforts (Butterfoss & Francisco, 2004). They can use these NCOA survey questions to track perceptions and actions of older adults and examine the impact of fall prevention activities over time. In addition to the questions reported here for older adults, survey questions exist for other important constituents, including caregivers, providers, and legislators (NCOA, n.d.c). These other stakeholders can play a role with nurses in reducing falls and injuries among older adults and make a difference for this vulnerable population.

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Summary of Evidence-Based Fall and Injury Prevention Interventions

CategoryInterventions
Screening

Routine screening for falls (e.g., history of single or multiple falls)

Medical risk assessment

Assessment and treatment of medical risks (e.g., gait, balance, mobility, foot disorders, postural hypotension, heart rate and rhythm disorders, vestibular disorders, vitamin D levels, calcium levels)

Medications

Annual medication review and reduction of high-risk drugs

Exercise/physical therapy

Regular exercise—tai chi or exercise that includes muscle strengthening, endurance, balance, and flexibility training

Referral to physical therapy for frail older adults or older adults with fear of falling who need guidance to begin physical activity programs or who are homebound

Vision impairment

Regular eye/vision examinations and treatment of cataracts

Home safety

Home safety assessment to address fall risks (e.g., lighting, tripping hazards, footwear)

Education

Referral to evidence-based fall prevention programs (e.g., Stepping On, A Matter of Balance, Otago exercise program)

Demographic Profile of Older Adult Survey Participants by History of Falls

Variable (Range)Mean (SD)p Value
Total (N = 267)Individuals Who Indicated Falling (n = 117)Individuals Who Did Not Indicate Falling (n = 132)
Age (53 to 94) (years)75 (9.1)74.1 (9.5)74.9 (8.6)0.54
Education (4 to 22) (years)14.5 (3)14.6 (3)14.6 (3)0.83
Number of chronic conditions (0 to 17)4.3 (2.6)5.1 (2.9)3.7 (2.2)<0.001
Number of physician visits in past 6 months (0 to 12)2.6 (2.4)2.8 (2.8)2.4 (2)0.17
Number of hospitalizations in past 6 months (0 to 5)0.16 (0.54)0.17 (0.57)0.15 (0.52)0.69
Fear of/concern about falling ratinga (0 to 10)4.4 (3.9)5.4 (3.8)3.5 (3.8)<0.001
Short FES-Ib (7 to 28)12.3 (4.9)13.5 (5.3)11.2 (4.4)0.001
n (%)
Gender0.11
  Female214 (81.4)98 (85.2)102 (77.3)
  Male49 (18.6)17 (14.8)30 (22.7)
Race/ethnicity0.16
  White214 (81.7)99 (86.8)105 (80.2)
  Other48 (18.3)15 (13.2)26 (19.8)
Use of walking aid49 (20.4)29 (26.9)17 (13.5)0.010
Fear of falling157 (63.8)84 (75.7)71 (53.8)<0.001

Older Adults' Awareness of, Beliefs about, and Actions to Reduce Risk of Falling

Characteristicsn (%)p Value
Total (N = 267)Individuals Who Indicated Falling (n = 117)Individuals Who Did Not Indicate Falling (n = 132)
Awareness of falling
  Injury from a fall ranked as a high concerna95 (55.6)51 (61.4)44 (50)0.13
  Importance of older adults taking steps to reduce fallsb (mean [SD])9.1 (1.7)9.11 (1.74)9.2 (1.6)0.83
Belief that they can do things to reduce risk of falling
  Somewhat or strongly agree with belief233 (94)109 (94)124 (93.9)0.99
  Neutral or disagree with belief15 (6)7 (6)8 (6.1)0.99
Actions to reduce risk of falling
  Took actions to reduce risk of falling in the past 12 months168 (70.9)82 (75.2)86 (67.2)0.17
  Talked to a family member or friend41 (17.3)26 (23.9)15 (11.7)0.01
  Talked to a health care provider47 (19.8)29 (26.6)18 (14.1)0.02
  Had vision checked98 (41.4)43 (39.4)55 (43)0.58
  Had medications reviewed by provider/pharmacist57 (24.1)27 (24.8)30 (23.4)0.81
  Participated in community fall prevention program33 (13.9)16 (14.7)17 (13.3)0.76
  Made changes in home107 (45.1)48 (37.5)59 (54.1)0.01
  Exercised regularly204 (83.3)90 (79.6)114 (86.4)0.16
    Exercise amount (days per week)0.23
    044 (18.6)24 (21.8)20 (15.9)
    1 or 271 (30.1)36 (32.7)35 (27.8)
    >2121 (51.3)50 (45.5)71 (56.3)
Total number of actions to reduce risk of fallingc (mean [SD])2.7 (1.7)2.9 (1.6)2.6 (1.8)0.14
Use of home safety checklist to identify home fall hazards59 (24.7)30 (27)29 (22.7)0.43
Authors

Dr. Lach is Professor, School of Nursing, Saint Louis University, St. Louis, Missouri; and Dr. Noimontree is Faculty of Nursing, Burapha University, Saensook, Mueang, ChonBuri, Thailand.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The authors acknowledge the other participants in the National Council on Aging workgroup who assisted with development of the evaluation questions: Mr. Michael Bauer, Dr. Jonathon Howland, Dr. Elizabeth Peterson, Ms. Rhonda Siegel, and Ms. Lynn Beattie. The authors also acknowledge the assistance of graduate students Tara Dauer, Terrilyn Quillen, and Alexandra Haas, who helped with data collection and data entry.

Address correspondence to Helen W. Lach, PhD, RN, CNL, FGSA, FAAN, Professor, School of Nursing, Saint Louis University, 3525 Caroline Mall, St. Louis, MO 63104; e-mail: helen.lach@slu.edu.

Received: February 01, 2018
Accepted: June 15, 2018

10.3928/00989134-20180808-06

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