Journal of Nursing Education

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Major Article 

Curriculum Strategies to Improve Baccalaureate Nursing Information Technology Outcomes

Marilyn S. Fetter, PhD, PMHCNS-BC

Abstract

Improving information technology (IT) outcomes is a top nursing education priority. Improving care access, quality, and cost effectiveness, IT skills are vital for professional development and advancement. Nursing programs have embraced distance learning and added informatics content, courses, and specific technologies; however, undergraduates’ and educators’ skills are still considered inadequate. Meanwhile, the Nursing Informatics specialty has moved beyond IT competency articulation and measurement. It is promoting information literacy to support evidence-based practice and the cultivation of clinical wisdom. The Technology Informatics Guiding Education Reform (TIGER) Initiative, a coalition aiming to advance IT outcomes in nursing education, has cited benchmarking and sharing best practices as key to achieving its goals. Thus, this article reports on the process, results, and implications of a project using curriculum strategies to enhance IT outcomes. A 3-year action plan directed faculty, student, and agency evaluation, curriculum mapping, model learning module, and documentation development.

Abstract

Improving information technology (IT) outcomes is a top nursing education priority. Improving care access, quality, and cost effectiveness, IT skills are vital for professional development and advancement. Nursing programs have embraced distance learning and added informatics content, courses, and specific technologies; however, undergraduates’ and educators’ skills are still considered inadequate. Meanwhile, the Nursing Informatics specialty has moved beyond IT competency articulation and measurement. It is promoting information literacy to support evidence-based practice and the cultivation of clinical wisdom. The Technology Informatics Guiding Education Reform (TIGER) Initiative, a coalition aiming to advance IT outcomes in nursing education, has cited benchmarking and sharing best practices as key to achieving its goals. Thus, this article reports on the process, results, and implications of a project using curriculum strategies to enhance IT outcomes. A 3-year action plan directed faculty, student, and agency evaluation, curriculum mapping, model learning module, and documentation development.

Dr. Fetter is Assistant Professor, Villanova University, College of Nursing, Villanova, Pennsylvania.

This work was partially funded by a grant from the Villanova University Institute for Teaching and Learning (VITAL).

Address correspondence to Marilyn S. Fetter, PhD, PMHCNS-BC, Assistant Professor, Villanova University, College of Nursing, 850 Lancaster Avenue, Villanova, PA 19085; e-mail: Marilyn.Fetter@villanova.edu.

Received: November 29, 2007
Accepted: April 24, 2008

Enhancing information technology (IT) competence is one of nursing’s most significant and urgent priorities. Experts agree that IT has vast potential to reduce health errors and improve care quality, access, and cost effectiveness. Thus, baccalaureate programs must prepare new nurses for current and future IT practice and innovation. Hospitals and agencies are pushing colleges to keep pace with what has been called a revolutionary movement in health care (McBride, 2005). The federal government’s electronic health initiative is another powerful force. Nursing education has embraced some technologies, such as distance learning and clinical simulation. However, recent studies document relatively weak IT knowledge and skills for students and faculty (McCannon & O’Neal, 2003; McDowell & Ma, 2007; McNeil et al., 2003; Ornes & Gassert, 2007). Absent in specific accreditation IT criteria, programs have proceeded individually but inconsistently with curricular initiatives, faculty development, and outcomes evaluation. An important impetus for progress occurred in 2006 with the launch of the Technology Informatics Guiding Education Reform (TIGER) Initiative (TIGER, 2007). A coalition of more than 20 nursing informatics and professional organizations and other stakeholders, the project aims to serve as a catalyst for accelerating informatics education and practice (TIGER, 2007). Its 3-year action plan emphasizes benchmarking, measuring, and disseminating best practices. Thus, this report describes one college’s efforts to improve IT outcomes. An action plan outlined the use of standardized informatics and information literacy competencies to direct outcomes evaluation, curriculum mapping, and model module and documentation development. The project process and outcomes can inform program and faculty initiatives and TIGER goals. More significantly, these results substantiate expert opinion calling for national nursing leaders and policy groups to make improving IT outcomes a top priority not only for education but for the entire profession.

Literature Review

The importance of informatics in nursing education has been affirmed and explored since the mid-1980s. Numerous policy and professional groups have cited IT competence as a critical beginning nurse skill linked to quality care (American Association of Colleges of Nursing, 1997, 1998; American Nurses Association [ANA], 1994, 1995, 2001; Canadian Nurses Association, 2006; Gassert & Salmon, 1998; Institute of Medicine, 2000, 2001a, 2001b, 2003a, 2003b, 2004a, 2004b; National League for Nursing [NLN], 1988, 2005, 2006; Pew Health Professions Commission, 1998; TIGER, 2007). Information literacy is another important baccalaureate graduate competency. The Association of College & Research Libraries’ information literacy outcomes for higher education are incorporated in regional University accreditation criteria, affecting all baccalaureate nursing programs (American Library Association, 2000).

The landmark documents by Staggers, Gassert, and Curran (2001, 2002) are the existing standard for IT competencies measurement for nurses. Rounds of expert opinion and validation yielded competencies for nurses at beginning, experienced, specialist, and expert levels. Foundational to the ANA’s Scope and Standards of Practice for Nursing Informatics (2001, 2008), it articulates 43 beginning nurse competencies. In 1998, the AACN cited informatics as a core competency for baccalaureate nursing. Neither it nor the National League for Nursing Accrediting Commission (NLNAC) have stipulated leveled, measurable outcomes in their most recent accreditation standards (CCNE, 2008; NLNAC, 2008).

Numerous studies have examined nursing students’ IT knowledge and skills. Recent research mirrors classic studies. In general, students perform relatively poorly except on the most basic skills (Cole & Kelsey, 2004; Gassert & McDowell, 1995; Jones, Navin, Barrie, Hillan, & Kinane, 1991). Strategies to improve students’ knowledge and skills have had modest results. Statistically significant increases in students’ informatics knowledge have been associated with computer training (Birx, Castleberry, & Perry, 1996) and a laptop initiative (Marini, 2000). Education and hardware provision was linked to improved skill and confidence levels (Birx et al., 1996; Graveley, Lust, & Fullerton, 1999; Kenney, 2002; Marini, 2000; Miller et al., 2005; Ndiwane, 2005). However, in another study, students’ and faculty ratings of students’ skills remained static 4 years after informatics and information literacy integration (Verhey, 1999). A longitudinal study comparing baccalaureate students’ self-ratings between matriculation and graduation found significant improvement in basic skills, bibliographic database, and statistical and presentation graphics program use; advanced skills, such as constructing spreadsheets and databases, did not change (McDowell & Ma, 2007).

Several investigators have questioned the role of IT in nursing education. Austin (1999) surveyed 184 faculty and found that of 60 skills, only confidentiality, literature searching, and word processing were well integrated into the 18 represented curricula. In another survey of 266 undergraduate deans and directors, more than 80% reported computer and information literacy skills as baccalaureate graduate expectations (McNeil et al., 2003). These administrators reported the integration of basic but not advanced informatics, no formal evaluation of student competencies, and ratings of faculty members teaching this content at the “novice” or “advanced beginner” level. Researchers evaluated a baccalaureate program’s curriculum by mapping course syllabi with the beginning competencies listed in the study by Staggers et al. (2001, 2002; Ornes & Gassert, 2007). Computer skills were frequently used, but limited work with computerized systems and no evidence of informatics exposure were found. A random survey of 752 members of the Association of Nurse Executives reinforces the need to strengthen nursing informatics content in nursing curricula. These leaders cited new nurse critical competencies beyond basic computer skills, such as familiarity with nurse-specific documentation and medication administration systems (McCannon & O’Neal, 2003). The literature review supported the importance of improving IT integration in nursing education, but provided limited evidence directing programs’ efforts to strengthen curriculum, faculty, and student outcomes.

Project Plan and Method

The nursing college, part of a sectarian university located in the mid-Atlantic region of the United States, has undergraduate, graduate, doctoral, and continuing education programs. The undergraduate program has more than 600 full-time students in generic, accelerated degree, and RN-to-BSN tracks. The program is predominately female, with students ranging in age from 17 to 60 and older. In 2004, the curriculum committee was asked to examine undergraduate program technology outcomes. Because no evaluation had been conducted, obtaining baseline data was identified as the first priority. A 3-year action plan calling for a literature review to identify best practices, curriculum, and student evaluation, as well as the recommendation of enhancement strategies, was enacted. An exhaustive literature review of policy statements, research reports, and position papers by experts in informatics, education, accreditation, nursing, and competencies measurement was conducted. Due to the lack of specific IT accreditation outcome standards, the competencies identified by Staggers et al. (2001, 2002) provided the philosophical underpinning of the project.

Phase one of the project called for the faculty evaluation of student outcomes and curriculum mapping (for the complete report, see Fetter, 2008). In a survey of the 40 full-time and 20 part-time faculty, 45% responded and evaluated students at a moderate skill level. Students’ were rated strongest in their positive attitudes and their use of communication technologies and basic office applications. Nursing-specific informatics abilities were rated lowest. Faculty reported widely varying policies and practices in theory, but especially in clinical courses. The lack of access to agency IT opportunities, no documentation of student requirements and outcomes, and legal and privacy concerns were noted. The curriculum mapping data were so inconsistent between and within courses that they were unusable. A similar method was used for student self-evaluation themselves (see Fetter, 2009). Of the 81 graduates, 52% responded; their assessments of moderate skill level and specific strengths essentially mirrored faculty evaluations. The new nurses called for more and fair access to “super-IT” agencies for clinical practica and faculty better prepared to teach and mentor informatics and information literacy content and practices.

Originally, the action plan called for the integration of IT enhancement strategies into the undergraduate curriculum. However, the curriculum and current experiences still needed to be validated. Virtually all of the full-time and the majority of part-time undergraduate faculty were convened to map the informatics and information literacy competencies by course; these were then validated with the entire group. Within theory courses, basic computing and literacy competencies were mapped relatively easily as expectations were fairly consistent across sections. Nursing-specific informatics competencies were not addressed in theory courses, an area noted for improvement. Information literacy outcomes were not leveled or documented, and many basic skills, such as conducting literature searches using databases, were repeated often. Evaluating and synthesizing literature and other evidence, and communicating results with clients, were cited for strengthening. Mapping within clinical practica was extremely difficult due to significant inconsistencies in agency access and opportunities. Students were not allowed access to clinical information systems in many agencies, and simulation experiences were not in place for students without agency experiences access to learn some of these skills. The faculty determined that students could graduate without hands-on experience because the college did not have documentation and tracking mechanisms and policies. More data regarding clinical agency practices and expectations were necessary to inform the project.

The survey of clinical agencies, was facilitated by the award of a small university teaching development grant. Again, the standard competencies provided the basis for the survey instrument, which also gathered data regarding current and projected institution policies with respect to IT and nursing programs (see Fetter 2008, 2009). Data were collected from 22 clinical agencies; identifying the most appropriate agency sources for IT information pertaining to nursing students was difficult. Multiple informants were often required and included nursing staff development, clinical education, informatics, and agency and unit managers. Agencies’ IT infusion ranged from no informatics systems to fully integrated IT functions, including one paperless system. Students and faculty access ranged from none to complete; opportunities varied widely between units within many institutions and between hospitals in health systems. Significant difficulties managing the IT demands of undergraduate nursing education were described, including resources constraints, privacy and security concerns, and training demands. Generally positive regarding clinical faculty skills, informants expressed frustration with nursing program administrators and senior faculty, who were perceived as “out of touch” with IT realities. Nursing programs were asked to take more responsibility for communication, training, leveling and documenting competencies, and advancing nursing IT through research and policy initiatives.

In phase two, three main areas of concern were targeted. Curriculum mapping incorporating the competencies of Staggers et al. (2001, 2002), Association of College & Research Libraries outcomes, and agency opportunities and expectations was conducted and validated by informatics, curriculum, and clinical specialty faculty experts. Based on the grid that was produced, a competencies documentation tool (Table 1) and policy recommendations were constructed. A sample module incorporating basic informatics and information literacy competencies was developed and validated for content by experts (Table 2). A schema for IT modules addressing all of the competencies and an evaluation plan is in progress. It is hoped that standardizing expectations for theory and clinical courses will reduce inconsistencies in curriculum implementation. In clinical agencies with limited or no access, the modules will provide a framework for devising nursing laboratory and simulation experiences. Faculty can now be held accountable for providing classroom and clinical instruction in specific IT areas. In the area of basic skills, the first module, transfer, accelerated, RN, and educationally disadvantaged students have a built-in primer for obtaining beginning computer literacy. The modules can also be used to help graduate and foreign students with limited informatics backgrounds. By entering the IT competencies into the college’s formal evaluation plan, responsibility for data collection and evaluation will be formalized. The strategies will be pilot tested and revised prior to full-scale implementation. Currently, funding and faculty time constraints are slowing the pace of project progress.

Informatics and Technologies Competencies Student Documentation Form

Table 1: Informatics and Technologies Competencies Student Documentation Form

Nursing, Health, and Academic Informatics and Technologies Competencies Learning Module One: Basic Computing Skills

Table 2: Nursing, Health, and Academic Informatics and Technologies Competencies Learning Module One: Basic Computing Skills

Implications

The process and outcomes of this project have implications for nursing education, research, practice, and national public policy. However, some limitations warrant cautious generalizability. The project was conducted in one school in one region of the United States. While using standardized, validated competencies, the author designed, conducted, and analyzed the survey results. Nevertheless, this project underscores many reports representing nursing faculty as a significant barrier to curricular IT initiatives (McCannon & O’Neal, 2003; McNeil et al., 2003; Ornes & Gassert, 2007; TIGER, 2007).

This project’s process and outcomes substantiates expert concerns that nursing faculty are a barrier to improving IT competencies in nursing education. To be fair, these and other faculty nationwide have many competing demands, such as research and publication, and developing advanced IT knowledge is not rewarded in most university systems. Until recently, motivated instructors had no flexible or funded mechanism for acquiring and updating IT skills. In the fall of 2007, the Health Information Technology Scholars (HITS) program was funded to improve the integration of technology competencies in nursing education by training educators to develop and implement innovation programs into curricula (Connors, 2008). Based on the Quality and Safety Education in Nursing framework, HITS will use Roger’s (1995) Innovation Diffusion Model to train five cohorts of nursing faculty members from collegiate programs. According to Rogers, innovations proceed in waves from early adopters progressing to later stage followers. Interventions using “innovation champions” have been successful in efforts to improve end-of-life care with physicians and nurses (Bookbinder et al., 2005). In one study, 75% of the nursing programs surveyed had an IT innovation champion faculty member (McNeil et al., 2003).

Basing IT integration on a diffusion model that uses waves of adopters and faculty trainers to promote faculty development is a promising strategy. It can be combined with linking vendors and agency nursing informatics experts to use resources cost effectively and ensure that faculty training and curriculum integration are congruent with regional IT practice. Nevertheless, leadership and collaboration, other pillars in the TIGER project, will be required to mobilize resources and obtain faculty and administrative buy-in. Unfortunately, the most recent research on curricular initiatives to improve students’ IT outcomes is not entirely promising (McDowell & Ma, 2007; Ornes & Gassert, 2007). Therefore, using a nationwide dissemination and train-the-trainer model focusing on improving faculty attitudes, knowledge, and behaviors may reap greater benefits.

For self-directed faculty learners, other resources are available. Online, Canada’s “NurseOne” site (Canadian Nurses Association, 2006) and the American Medical Informatics Association (2007) Nursing Informatics section provide information on evidence, applications, and training, but require access and skills beyond the basic level. Faculty composition and shortages are compounding the problem. Agencies were positive regarding clinical instructors. However, in many institutions, they have adjunct or part-time status and are not incorporated into regular faculty and curricular discussions. Aging nursing faculty rapidly approaching retirement may have limited motivation to pursue IT continuing education and course revision. Newly hired PhD-prepared nurse faculty have the arduous task of developing and funding a program of research as a competing and more pressing demand. Thus, a more strategic approach should be considered to move faculty and curricula forward.

There is growing consensus that nurse educators and programs need to take greater responsibility for faculty and student competence for nurses to use IT to improve patient care (McDowell & Ma, 2007; McNeil et al., 2003; TIGER, 2007). By 2014, the federal government has mandated a fully automated electronic health record (U.S. Department of Health and Human Services, 2004). The plan calls for IT to be completely integrated into patient care. The Veteran’s Administration (2007) is currently close to realizing this goal. Consequently, many education and informatics experts are now calling for informatics content integration throughout nursing curricula, not in a single course (Barton, 2005; Carty & Ong, 2006; Chastain, 2002; Connors, Weaver, Warren, & Miller, 2002; Ehnfors & Grobe, 2006; McCannon & O’Neal, 2003; TIGER, 2007). Given the realities of faculty IT preparation and rewards, this objective does not seem achievable without stronger leadership and support from collegiate nursing deans and directors. The sponsoring and supporting entities of TIGER and HITS can move informatics into the mainstream of nursing practice and education, but only if funding is available to support faculty education and development, curriculum reform evaluation and dissemination, research initiatives, and policy development. It is clear that many nursing programs will need the pressure of specific accreditation criteria to motivate faculty and administrators and to secure university funds.

Agency and nursing accreditation bodies can support educational programs and patient care safety and quality by mandating student IT education, monitoring, and evaluation. Agencies can use their leverage to encourage vendors to do the right thing. It is time for national nursing education and health management policy groups to quantify and make this argument persuasively. Partnerships to make hardware and software available to programs is an effective educational strategy (Connors et al., 2002) that can also develop brand comfort and loyalty with future nurse executives and educators. However, most nursing education programs do not have the resources to purchase clinical information systems and support their operation. This project and research shows the risks for serious compromises in privacy, care quality, and medication errors when students’ IT access is denied or limited and not monitored (Institute for Safe Medication Practice, 2007; Thompson & Bell, 2007; Wagner, Thoman, Anumalasetty, Hardre, & Ross-Lazarov, 2002; Wimberley et al., 2005). In addition, current practices to manage student agency IT training, access, and monitoring are breaking down (Fetter, 2008). Vendors, agencies, and educational programs must devise a better, cost-effective approach to integrating nursing students’ IT learning and practice.

The nursing profession is missing critical opportunities to realize the full potential of health information technology because faculty lack the skills and funding to advance IT competency integration. Investigators have demonstrated the effectiveness of numerous IT interventions to improve care quality, access, and cost effectiveness (Alwan, Aversano, Matthews, & Rosen, 2004; American Academy of Nursing, 2003; Bakken, Cimino, & Hripcsak, 2004; Cowden & Johnson, 2004; Riner, Cunningham, & Johnson, 2004; Van de Castle, Kim, Pedreira, Goosen, & Bates, 2004). In terms of health promotion with patients, families, and communities, IT has vast potential (Booth, 2006). However, such initiatives require computer, informatics, and health information literacy skills (Saranto & Hovenga, 2004) and evaluation research to identify effective strategies. Patient advocacy is moving to a new dimension as a host of affective, legal, ethical, and privacy questions associated with health informatics arise (Jada & Delamothe, 2004). Nursing faculty and students are poised to engage in these research and clinical efforts to promote health and health literacy for patients, families, and communities in the digital age. However, unless nursing faculty and researchers are IT competent, they are incapable of joining, let alone leading, the IT revolution in health care (Barnard, Nash, & O’Brien, 2005; Lamb, Jennings, Mitchell, & Lang, 2004). The newly released ANA (2008) Scope and Standards of Practice for Nursing Informatics reflect this IT competency chasm. Nursing Informatics has moved beyond competency articulation to information literacy and wisdom cultivation (Staggers, personal communication, March 13, 2008). Nurse educators must rise to meet these expectations.

Conclusion

A college of nursing implemented a two-phase, multistage initiative to enhance IT outcomes. Standardized informatics and information literacy competencies informed the project, which included faculty, graduating student, agency, and curriculum evaluation. Numerous barriers to competency attainment were identified. Wide variations in access to informatics and technologies in clinical agencies and inconsistent integration of informatics content into theory and clinical courses were reported as the greatest inhibitors of student competency attainment. Lack of faculty knowledge, skills, and motivation to integrate IT skills into the curriculum was also identified as a significant challenge. The literature and data collected support the claim that nurses’ poor IT competence is a threat to patient care quality and is not simply an educational issue. This project demonstrated that IT, information literacy, and agency competency expectations and documentation can be integrated into undergraduate nursing curricula. A model module was developed that is planned for pilot testing. However, improving nursing education IT outcomes is challenging and resource intensive. Policy initiatives are necessary to induce nursing programs, clinical agencies, vendors, and accrediting bodies to collaborate to facilitate the adoption and integration of standardized IT and information literacy competencies into curricula and clinical practica. Initiatives such as TIGER and HITS have the potential to improve nursing education, practice, and research. However, moving nursing faculty will require leadership, consensus, policies, and funding. Unless effort and resources are committed, nursing education, practice, and research may be left behind in the IT revolution.

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Informatics and Technologies Competencies Student Documentation Form

CourseStaggersaInformation literacy bloom levelAgencies Rotation IAgencies Rotation IIFaculty/Date/StudentComments
NUR 1101 Introduction to Professional Nursing3, 4, 6, 7, 11, 19, 20, 21, 22, 24, 26, 27, 28, 29, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41Knowledge comprehensionN/AN/A
NUR 1103 Introduction to Professional Nursing II9, 10, 16, 23ApplicationN/AN/A
NUR 2104 Nursing Processes & Health Assessment16ApplicationN/AN/A
NUR 2105 Nursing Processes & Health Assessment IIApplicationN/AN/A
NUR 2106 Essentials of Nursing PracticeApplicationN/AN/A
NUR 2107 Practicum of Essentials In Nursing Practice8, 13, 15, 38, 42ApplicationElectronic medical records
NUR 2120 Principles of NutritionAnalysesWeb
NUR 3112 Nursing Care of AdultsAnalyses
NUR 3113 Nursing Care of Adults Practicum14, 18, 25AnalysesMonitoring technologies
NUR 3116 Nursing Care of Adults with Complex Health Problems
NUR 3117 Nursing Care of Adults with Complex Health Problems Practicum5, 12,30SynthesisWeb care resources
NUR 4101 Parent-Child NursingEvaluate
NUR 4103 Parent-Child Nursing Practicum30EvaluateAdvanced monitors
NUR 4130 Issues and Trends In NursingEvaluate
NUR 4102 Community Health Nursing & Health PromotionEvaluateGlobal Web databases
NUR 4107 Practicum in Community Health Nursing & Health Promotion1, 2, 17EvaluateOASIS, practice management, billing
NUR 4110 Nursing Management & Leadership43EvaluateAgency management

Nursing, Health, and Academic Informatics and Technologies Competencies Learning Module One: Basic Computing Skills

Instructions

Read and sign the university’s and college of nursing’s computing, Internet and academic policy statements. Fax signed statements to the nursing office.

Log on to the computer. Identify directories, help, online, wireless, and printing capabilities and resources.

Use internet browser to access the university Web site. Log on and reset password.

Access personal e-mail. Read, respond to, and delete the advisor welcome message.

Read NUR 1101 course instructor welcome. Create computer file folders for course materials and assignments.

Form project presentation small group. Create listserv group. Send hello e-mail to group and print. Forward one welcome e-mail from a group member to another group member. Create address book and enter all group members.

Load printer with paper. Identify toner cartridge and jam areas.

Access Microsoft Office Word® manual on the university’s Informatics Technology (UNIT) department’s Web site and create a bookmark for the Web site.

Access course Web site on the university’s online course management system. Download assignment one, “Critical Thinking Response—McBride, A. (2005). Nursing and the informatics revolution. Nursing Outlook, 4, 183–191.” File in personal computer file and print. Respond to critical thinking questions posted on Vista-CT, save as a document in a folder, and attach to an e-mail. Submit to the instructor electronically.

Download the article by McBride and response to diskette, CD, jump or “flash”, and zip drives. Copy to the computer’s hard drive.

Backup files onto CD.

Access the merged document on the hard drive. Copy the first paragraph and create a new document. Reformat the document margins. Use the following document features: indent, line spacing, underline, center, italics, bold. Insert the first paragraph of your critical thinking response as a second paragraph. Save as “assignment two” and print.

Access assignment two. Move a sentence within the document. Use the Publication Manual of the American Psychological Association (2001) to create a reference page. Create a header and paginate the document. Use the thesaurus tool to change a word in the first sentence of the first paragraph. Use spell check to obtain word count. Save as “assignment three,” attach to e-mail, and forward electronically to the instructor.

Send assignment three to the group listserv and then to only one individual in the group. Respond to the e-mail from your group and delete. Respond to individual e-mail from the group after checking text and renaming.

Defragment the computer and identify the system restore feature.

Authors

Dr. Fetter is Assistant Professor, Villanova University, College of Nursing, Villanova, Pennsylvania.

Address correspondence to Marilyn S. Fetter, PhD, PMHCNS-BC, Assistant Professor, Villanova University, College of Nursing, 850 Lancaster Avenue, Villanova, PA 19085; e-mail: .Marilyn.Fetter@villanova.edu

10.3928/01484834-20090201-06

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