Journal of Nursing Education

Research Briefs 

Critical Care Interprofessional Education: Exploring Conflict and Power—Lessons Learned

Mary Louanne Friend, PhD, MN, RN; Richard D. Friend, MD, FAAFP; Cassandra Ford, PhD, MSN, MBA, RN, FAHA; Patrick J. Ewell, PhD

Abstract

Background:

The purpose of this mixed-methods study was to evaluate the effects of an innovative critical care interprofessional education intervention on prelicensure nursing and medical students at a large public university. The class provided opportunities for students to (a) explore stereotypes about each respective profession, (b) examine the occurrence and effects of interprofessional conflict in high-acuity areas, and (c) explore conflict resolution techniques while learning how to perform critical care procedures as a team.

Method:

A nonequivalent control group design with pretest, posttest, and focus group interviews were used.

Results:

Data analyses indicated no subscales and total scores were significantly different across time or between groups. However, focus group analyses indicated that changes did occur.

Conclusion:

The findings suggest that students experience interprofessional conflict in clinical settings, yet lack the confidence and skills to effectively mitigate these behaviors. Ongoing studies to measure student empowerment and their intentions to practice collaboratively before and after graduation are recommended. [J Nurs Educ. 2016;55(12):696–700.]

Abstract

Background:

The purpose of this mixed-methods study was to evaluate the effects of an innovative critical care interprofessional education intervention on prelicensure nursing and medical students at a large public university. The class provided opportunities for students to (a) explore stereotypes about each respective profession, (b) examine the occurrence and effects of interprofessional conflict in high-acuity areas, and (c) explore conflict resolution techniques while learning how to perform critical care procedures as a team.

Method:

A nonequivalent control group design with pretest, posttest, and focus group interviews were used.

Results:

Data analyses indicated no subscales and total scores were significantly different across time or between groups. However, focus group analyses indicated that changes did occur.

Conclusion:

The findings suggest that students experience interprofessional conflict in clinical settings, yet lack the confidence and skills to effectively mitigate these behaviors. Ongoing studies to measure student empowerment and their intentions to practice collaboratively before and after graduation are recommended. [J Nurs Educ. 2016;55(12):696–700.]

Current interprofessional education (IPE) has been criticized for ignoring both power disparities between medicine and nursing and interprofessional conflict (Meleis, 2016; Paradis & Whitehead, 2015). This omission is significant given that conflict between physicians and nurses is common in high acuity areas worldwide (Azoulay et al., 2009; Olson, Brasel, Redmann, Alexander, & Schwarze, 2013). Whereas nurses and physicians are primarily educated in isolation from one another (Karimi, Pelham-Foster, Scott, & Aamodt, 2012), students may be unable to overcome stereotypical ideas, explore interprofessional conflict, and effectively decrease disruptive behaviors in the health care setting.

The purpose of this article is to describe the development, delivery, and effects of a semester-long interprofessional critical care elective at a large public university for prelicensure nursing and medical students. The 2-hour class was cotaught by nursing and medical faculty during the 2015 spring semester. The class was designed to provide opportunities for students to (a) explore stereotypes about each respective profession, (b) examine the occurrence and effects of interprofessional conflict in high-acuity areas, and (c) explore conflict resolution techniques while learning how to perform critical care procedures as a team.

This pilot study used a mixed-methods design to explore the following questions: what are the attitudes of fourth- and fifth-semester undergraduate nursing and third- and fourth-year medical students about critical care health care teams and IPE, and knowledge of roles and scope of practice of health care members before and after a psychosocial intervention? What changes did the students experience as a result of the course? Results of data analyses using Predictive Analytics Software (PASW version 18.0), and qualitative results of two student focus groups are presented.

Background

Poor communication between nurses and physicians in critical care environments may be the most significant factor associated with excess hospital mortality (Manojilovich & DeCicco, 2007). The potentially negative effects of hostile nurse–physician relationships on patient care include increased errors and patient mortality and compromises in safety and quality (Rosenstein & O'Daniel, 2008). In contrast, nurse–physician collaboration has been positively associated with decreased infections in critical care units and increased retention of critical care nurses (Boev & Xia, 2015; Sawatzky, Enns, & Legare, 2015).

Perhaps the most complex barrier to overcome in efforts to decrease interprofessional conflict is a lack of emphasis within IPE on the development of soft skills, including how to dispel stereotypical ideas about one another's roles and how to effectively cope with discord. Although student instruction to manage horizontal violence has been recommended (Curtis, Bowen, & Reid, 2007) and successfully piloted in nursing education (Pines et al., 2014), little information exists about these types of courses within the interprofessional literature. Current undergraduate IPE efforts have been described as failing to address understanding of professional roles, authority, and gender-related dimensions of teamwork (Aase, Hansen, & Aase, 2014). If nurses and physicians are able to socialize to their collaborative roles during their education (Hartog & Benbenishty, 2015), one can hypothesize that nursing and medical students who learn together prior to licensure may be better prepared to develop healthy working relationships.

Teaching Philosophy

Traditional pedagogy for nursing and medicine has been described as outdated and unable to address the needs of populations (Meleis, 2016). Nursing education has also been criticized for being oppressive and submissive and in need of a paradigm shift where the “student is engaged in the process of developing autonomy and empowerment” (Allen, 2010, p. 36). If nurse educators are expected to prepare students to lead health care reform (Institute of Medicine, 2010), programs must provide opportunities for their students to articulate to others what nursing actually is and what it is not (Sommerfeldt, 2013). To create an empowered learning environment, course faculty used grading criteria based solely on class participation, required no homework assignments, and engaged with students in authentic dialogue about actual experiences involving interprofessional conflict.

Course Schedule, Content, and Teaching Methods

Creating a schedule, choosing content, and identifying measures to maximize student engagement and empowerment were only a few of the challenges faculty faced during the year-long planning process. Ultimately, administrative support from both colleges and student enthusiasm for learning critical care procedures in an interprofessional environment were fundamental to the success of the course. By limiting enrollment to a total of 21 students (i.e., 10 nursing and 11 medical), student-driven instruction was promoted. Students met for 2 hours each week in the classroom and clinical practice laboratory. The course culminated with a high-fidelity simulation during which students managed a gunshot wound victim as teams.

Course Content

Stereotypes in health care were discussed during the first class and throughout the semester. During week 1, students were asked to introduce themselves and to openly discuss their perceptions of each other's profession and roles. Student responses ranged from the humorous, “I hoped that all of the medical students would look like George Clooney,” to more stereotypical remarks, including “Physicians are the leaders of health care teams”. These preconceived ideas and their potential effects on health care teams were discussed weekly as both students and faculty shared positive and negative clinical experiences where stereotypes had played a role.

The positive correlation between the lack of communication with sentinel events was also discussed during the semester (Joint Commission, 2008). Students worked collaboratively to dissect the multiple breaks in communication that resulted in the death of a real patient in an emergency department while also completing a mock root cause analysis. Students also spent one class identifying their preferred mode of conflict resolution (Kilmann & Thomas, 1977) and then used role-play to practice deescalating interprofessional conflict. Excerpts from Bedside Manners (Gordon, Hayes, Reeves, & Leape, 2013) were used to facilitate learning.

Clinical skills were incorporated within the class in an effort to maximize the opportunity for students to teach each other, thereby promoting shared learning and student empowerment. Sample topics taught by faculty included central line insertion, airway management and intubation, principles of trauma care, and chest tube insertion. Nursing students paired with medical students to teach them how to insert intravenous and Foley catheters, in addition to the latest evidenced-based practice related to staging pressure ulcers. The medical students demonstrated their suturing skills with the nursing students.

Method

A nonequivalent control group design with a pretest, post-test, and focus group interviews were used. The sample included 46 medical and nursing students from the university. The control group contained 12 third- and fourth-year medical and 13 fourth- and fifth-semester nursing students. The experimental group contained 10 nursing and 11 medical students who were selected to complete the course during the 2015 spring semester.

Data Collection

University institutional review board approval was obtained prior to data collection in the 2015 spring semester, and signed consents were obtained. The control group contained fourth- and fifth-semester nursing students and third- and fourth-year medical students who did not participate in the intervention. The experimental group (N = 21) was a convenience sample of students who self-elected to take the course. Surveys were electronically sent via Qualtrics© during the first and last 2 weeks of the semester.

Surveys, selected to measure student knowledge, skills, and attitudes, included the Attitudes toward Interprofessional Healthcare Teams Scale (ATHCT; Heinemann, Schmitt, Farrell, & Brallier, 1999), the 17-item Team Skills Scale (TSS; Hepburn, Tsukuda, & Fasser, 1998), and the 18-item Interdisciplinary Education Perception Scale (IEPS; Luecht, Madsen, Taugher, & Petterson, 1990). The 20-item ATHCT was designed to measure attitudes about teamwork and has two subscales: quality of care/process and shared leadership/physician centrality. The TSS, a self-assessment instrument, was developed to measure individual skills, including interpersonal- and discipline-specific abilities. The IEPS measures four attitudes critical to interprofessional practice and has four subscales: professional competency and autonomy, perceived need for cooperation, perception of actual cooperation, and understanding the value and contributions of others.

The focus groups were conducted at the end of the semester. Both groups were heterogeneous, with equal numbers of medical and nursing students in the first group and six medical and five nursing students in the second group. Interview transcripts were read verbatim by both researchers until dominant ideas emerged. Collaborative, inductive thematic analysis was used to identify themes relevant to the research questions (Fereday & Muir-Cochrane, 2006). An independent researcher was then asked to verify the categories identified within the data.

Instrument Reliability

All measures, including subscales, were checked for reliability. Because the low sample violates the assumption of Cronbach's alpha (Cronbach, 1951), Guttman's Lambda -2 (Guttman, 1945) was used in each instance. All measures or subscales were checked for reliability at both Time 1 and Time 2 and are reported in Table 1. Clearly, a few instances exist where the reliability was lower than desired. However, in the case of the ATHCT: Team efficiency and the IEPS: Understanding own time categories, a small number of items exist that make reliability difficult to measure. All three of these scales have been previously tested regarding validity and those studies have been cited.


Subscale Guttman's Lambda −2

Table 1:

Subscale Guttman's Lambda −2

Data Analysis

Of the 46 participants, two did not complete the entire survey at Time 1 and five participants who completed Time 1 did not complete Time 2. In addition, six participants who completed Time 2 did not complete the Time 1 measurement, leaving 33 participants with complete data for the main analysis. All participants who did not complete both time points in their entirety were excluded from the main analysis.

Paired data analyses (i.e., the differences between Time 1 and Time 2) were conducted via the Wilcoxon Sign test for paired samples. Between groups differences were tested using the Mann-Whitney U test for independent samples. In addition, a repeated measures analysis of variance (ANOVA), using time as the within-subject factor and groups as the between-subject factor, was conducted to understand the full interaction between factors. Data analyses was completed using PASW Version 18 software.

Results

Results from the study were mixed. Between-groups differences were tested using the Mann-Whitney U test for independent samples and showed only one significant difference between the groups. Those in the experimental group (mean time 1 [Mt1] = 13.78, Mt2 = 16.62) had lower scores on the perception subscale of the IEPS compared with those in the control group (Mt1 = 20.87, Mt2 = 24.79) at both Time 1 (U = 77, p = .035) and Time 2 (U = 118, p = .026). As this difference for both groups increased insignificantly overtime, it appears to be a natural artifact of the groups.

Repeated-measures ANOVA showed that no subscale or total scores were significantly different across time or between groups (Table 2). The researchers attributed this to the small sample size (N = 31) and noted that some measures did produce small effect sizes for change across time (ηp2 = .02 to .04). Some differences were seen between groups in regards to medical students versus nursing students. The student type variable was used as a between-subjects grouping variable via a series of Mann-Whitney U tests. These tests revealed that medical students (mean = 10.64) had significantly lower scores in regards to ATHCT Team values compared with nursing students at Time 1 (mean = 23.11) but not at Time 2 (U = 51, p = .001). Medical students (Mt1 = 7.32, Mt2 = 6.56), compared with nursing students (Mt1 = 24.46, Mt2 = 20.87), also had significantly lower ratings for ATHCT physician team leadership at both Times 1 and 2 (Ut1 = 14.5, pt1 < .001; Ut2 = 16.5, pt2 < .001). Finally, medical students (Mt1 = 10.25, Mt2 = 10.03) had significantly lower scores compared with nursing students (Mt1 = 22.24, Mt2 = 19.77) in regards to perceptions subscale of the IEPS at both Time 1 and Time 2 (Ut1 = 47.5, pt1 =.002; Ut2 = 45.0, pt2 =.015). These lower scores in regards to ATHCT Team values may suggest that the medical students gained an appreciation for the value of teamwork during the class. Of interest, the medical students lower scores on the ATHCT, the physician centrality subscale that measures team members' attitudes toward physicians' authority and their control over information about patients, suggests that they did not perceive doctors as having the ultimate influence in decision making, compared with the nursing students. Also, the medical students' lower scores for the perception scale of the IEPS that measures awareness of interdisciplinary cooperation may suggest that they did not value or witness collaborative practice in the clinical setting. However, it should be noted that for these analyses, the medical student group was nearly half of the nursing student group, so these results should be interpreted with caution. Using a repeated measures ANOVA with the type of student as the between-group factor, there were no time × group interactions. Although all quantitative analyses were nonsignificant, qualitative analyses provided rich information. Four major themes were identified: (a) Learning in a Nonjudgmental, Relaxed Environment, (b) Changes in Preconceived Perceptions, (c) Camaraderie, and (d) Increased Awareness of Interprofessional Conflict.


Between Group Point Estimates and 95% CIs

Table 2:

Between Group Point Estimates and 95% CIs

Learning in a Nonjudgmental, Relaxed Environment

The relaxed approach to the course was well received, as students reported they enjoyed the opportunity to interact and to learn without worrying about grades. One nursing student said, “Not having a grade attached made it a fun class. We learned, but we weren't stressed about learning,” and a medical student said, “I really liked it because in most courses you have to study intensely before the class. This class was very nice because after a hard day at clinical you could come here and talk and relax.”

Changes in Preconceived Perceptions

Recurring statements from medical students included their surprise by the nursing students' depth of knowledge. One medical student said, “I thought that nurses learned if X happens then you do Y. But they know why you do Y when X occurs.” Another nursing student said:

I knew the shortcomings of our curriculum but I never understood that medical students also have problems. They seem to be on their own to practice skills and depend on nurses in the hospitals to help them just like we do.

Camaraderie

Both nursing and medical students reported feeling a sense of community as a result of the course. A female medical student said

I think it was cool when we shared our experiences, the good and the bad, like having good preceptors and bad ones. It was nice to know that medical students and nursing students have the same experiences. As a result, there was camaraderie as students.

Of interest, female medical and nursing students reported being treated differently by nurses and medical staff than their male counterparts, stating “We don't know what we are doing.” Likewise, female students reported being asked by patients and their families “when they were going to get married and start a family.”

Increased Awareness of Interprofessional Conflict

Students confirmed that although they had heard a good deal about interprofessional collaboration, they had not witnessed it in the clinical areas. One nursing student said:

I have never had a conversation with my patient's physician in the hospital setting. I am not comfortable in approaching them and do not see them speaking to the regular nursing staff about their patients. They seem to go in and out so quickly that there is little time to talk.

Many students also openly described either being the direct victim of or witness to conflict in the health care setting, and their powerlessness as students to effectively cope with these disruptive behaviors. A medical student stated:

I knew how much nurses do, but the thing I learned was about how the nursing students have been talked down to by doctors. I didn't know that was a thing anymore. I thought it was something that doesn't happen anymore.

Discussion

This data set has several limitations. First, the sample size is smaller than what would be preferred when conducting a repeated measures ANOVA. Second, it is possible that the measures selected may not have been sufficient to detect the change that was taking place within the course group. Another limitation is that there were five men in the experimental group and none in the control group. Whether it impacted the data would be difficult to tell.

Student lack of understanding about how each discipline is educated and the stereotypical concepts that exist suggest this type of course is valuable. Of specific note was medical students' surprise at the nursing students' depth of knowledge and their reports that they would collaborate with nurses in the future based on this enhanced awareness. If medical students develop respect for nursing's contribution to patient care, perhaps they may be more inclined to work together in the clinical setting. The acknowledgement that both the nursing and medical students were dependent on the support of staff nurses to succeed was a valuable experience for all, and may underscore to all students the potential toxic effects of conflict between the professions. Finally, the lack of collaboration that both groups of students witnessed in the clinical area suggest that the traditional, hierarchal models of health care are still widely practiced in acute care settings.

Conclusion

These findings suggest that students experience interprofessional conflict in clinical settings required for training, yet lack the confidence and skills to effectively mitigate these behaviors. If students do not have an opportunity to share their experiences and to actively engage in real problem solving, who, then, will be able to transform the ongoing culture of conflict in health care? Although the findings of this study cannot be generalized, one can suppose that without structured opportunities to explore the antecedents and consequences of interprofessional conflict, nursing and medicine will be less able to provide their stakeholders with the collaborative, patient-centered care they deserve.

To evaluate whether changes in knowledge and attitudes are indeed successful in decreasing conflict and increasing collaboration between the two disciplines, longitudinal national studies, where cohorts of students are evaluated before and after graduation, are indicated. Future research may also involve designing instruments that measure student empowerment and their intentions to practice collaboratively as a result of IPE.

References

  • Aase, I., Hansen, B.S. & Aase, K. (2014). Norwegian nursing and medical students' perception of interprofessional teamwork: A qualitative study. BMC Medical Education, 14, 170. doi:10.1186/1472-6920-14-170 [CrossRef]
  • Allen, S. (2010). The revolution of nursing pedagogy: A transformational process. Teaching and Learning in Nursing, 5, 33–38. http://dx.doi.org/10.1016/j.teln.2009.07.001 doi:10.1016/j.teln.2009.07.001 [CrossRef]
  • Azoulay, E., Timsit, J.F., Sprung, C.L., Soares, M., Rusinová, K. & Lafabrie, A.Conflicus Study Investigators and for the Ethics Section of the European Society of Intensive Care Medicine. (2009). Prevalence and factors of intensive care unit conflicts: The Conflicus study. American Journal of Respiratory and Critical Care Medicine, 180, 853–860. doi:10.1164/rccm.200810-1614OC [CrossRef]
  • Boev, C. & Xia, Y. (2015). Nurse-physician collaboration and hospital-acquired infections in critical care. Critical Care Nurse, 35, 66–72. doi:10.4037/ccn2015809 [CrossRef]
  • Cronbach, L.J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297–334. doi:10.1007/BF02310555 [CrossRef]
  • Curtis, J., Bowen, I. & Reid, A. (2007). You have no credibility: Nursing students' experiences of horizontal violence. Nurse Education in Practice, 7, 156–163. doi:10.1016/j.nepr.2006.06.002 [CrossRef]
  • Fereday, J. & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5, 80–92.
  • Gordon, S., Hayes, L., Reeves, S. & Leape, L.L. (2013). Bedside manners: Play and workbook. New York, NY: Cornell University Press.
  • Guttman, L. (1945). A basis for analyzing test-retest reliability. Psychometrika, 10(4), 255–282. doi:10.1007/BF02288892 [CrossRef]
  • Hartog, C.S. & Benbenishty, J. (2015). Understanding nurse–physician conflicts in the ICU. Intensive Care Medicine, 41, 331–333. doi:10.1007/s00134-014-3517-z [CrossRef]
  • Heinemann, G.D., Schmitt, M.H., Farrell, M.P. & Brallier, S.A. (1999). Development of an attitudes toward health care teams scale. Evaluation and the Health Professions, 22, 123–142. doi:10.1177/01632789922034202 [CrossRef]
  • Hepburn, K., Tsukuda, R.A. & Fasser, C. (1998). Team skills scale, 1996. In Siegler, E.L., Hyer, K., Fulmer, T. & Mezey, M. (Eds.), Geriatric interdisciplinary team training (pp. 264–265). New York, NY: Springer.
  • Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956&page=R1
  • Joint Commission. (2008). Sentinel event alert, issue 40: Behaviors that undermine a culture of safety. Retrieved from http://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/
  • Karimi, R., Pelham-Foster, S., Scott, B.J. & Aamodt, G. (2012). Developing and implementing an interprofessional course and identifying its strengths and challenges. Health and Interprofessional Practice, 1, eP1019. http://dx.doi.org/10.7772/2159-1253.1019 doi:10.7772/2159-1253.1019 [CrossRef]
  • Kilmann, R.H. & Thomas, K.W. (1977). Developing a forced-choice measure of conflict-handling behavior: The” MODE” instrument. Educational and Psychological Measurement, 37, 309–325. doi:10.1177/001316447703700204 [CrossRef]
  • Luecht, R.M., Madsen, M.K., Taugher, M.P. & Petterson, B.J. (1990). Assessing professional perceptions: Design and validation of an Interdisciplinary Education Perception Scale. Journal of Allied Health, 19, 181–191.
  • Manojlovich, M. & DeCicco, B. (2007). Healthy work environments, nurse-physician communication, and patients' outcomes. American Journal of Critical Care, 16, 536–543.
  • Meleis, A.I. (2016). Interprofessional education: A summary of reports and barriers to recommendations. Journal of Nursing Scholarship, 48, 106–112. doi:10.1111/jnu.12184 [CrossRef]
  • Olson, T.J.P., Brasel, K.J., Redmann, A.J., Alexander, G.C. & Schwarze, M.L. (2013). Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surgery, 148, 29–35. doi:10.1001/jamasurgery.2013.403 [CrossRef]
  • Paradis, E. & Whitehead, C.R. (2015). Louder than words: Power and conflict in interprofessional education articles, 1954–2013. Medical Education, 49, 399–407. doi:10.1111/medu.12668 [CrossRef]
  • Pines, E.W., Rauschhuber, M.L., Cook, J.D., Norgan, G.H., Canchola, L., Richardson, C. & Jones, M.E. (2014). Enhancing resilience, empowerment, and conflict management among baccalaureate students: Outcomes of a pilot study. Nurse Educator, 39, 85–90. doi:10.1097/NNE.0000000000000023 [CrossRef]
  • Rosenstein, A.H. & O'Daniel, M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. The Joint Commission Journal on Quality and Patient Safety, 34, 464–471. doi:10.1016/S1553-7250(08)34058-6 [CrossRef]
  • Sawatzky, J.A.V., Enns, C.L. & Legare, C. (2015). Identifying the key predictors for retention in critical care nurses. Journal of Advanced Nursing, 71, 2315–2325. doi:10.1111/jan.12701 [CrossRef]
  • Sommerfeldt, S.C. (2013). Articulating nursing in an interprofessional world. Nurse Education in Practice, 13, 519–523. doi:10.1016/j.nepr.2013.02.014 [CrossRef]

Subscale Guttman's Lambda −2

Scale and SubscaleTime 1 λTime 2 λ
ATHCT: Team values.789.741
ATHCT: Team efficiency.425.542
ATHCT: Physician leadership.696.671
TSS.884.839
IEPS: Autonomy.807.824
IEPS: Understanding own time.086.419
IEPS: Perception.798.858
IEPS: Understanding others' time.197.644

Between Group Point Estimates and 95% CIs

Scale and SubscaleControl Group (CI = 95%)Experimental Group (CI = 95%)


MLowerUpperMLowerUpper
ATHCT: Team values4.784.604.974.684.504.85
ATHCT: Team efficiency4.083.854.324.093.874.31
ATHCT: Physician leadership3.262.883.642.892.543.24
TSS38.6736.2241.1136.0033.7038.30
IEPS: Autonomy4.804.505.104.744.465.02
IEPS: Understanding own time5.475.215.725.465.225.70
IEPS: Perception5.154.865.444.64.334.87
IEPS: Understanding others' time4.414.044.784.213.864.56
Authors

Dr. Mary Louanne Friend is Assistant Professor, and Dr. Ford is Associate Professor, Capstone College of Nursing, and Dr. Richard Friend is Associate Professor and Chair and Residency Director, Department of Family Medicine, College of Community Health Sciences, Tuscaloosa Family Medicine Residency Program, University of Alabama, Tuscaloosa, Alabama; and Dr. Ewell is Visiting Assistant Professor, Department of Psychology, Kenyon College, Gambier, Ohio.

This research was funded by an RGC Level one grant by The University of Alabama.

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

Address correspondence to Mary Louanne Friend, PhD, MN, RN, Assistant Professor, Capstone College of Nursing, University of Alabama, Box 870358, Tuscaloosa, AL 35487-0358; e-mail: mlfriend@ua.edu.

Received: March 27, 2016
Accepted: August 23, 2016

10.3928/01484834-20161114-06

Sign up to receive

Journal E-contents