Research in Gerontological Nursing

Research Brief 

Depression Treatment in Assisted Living Settings: Is an Innovative Approach Feasible?

Marianne Smith, PhD, RN; Christine Haedtke, MSN, RN

Abstract

Depression is a common, disabling, and underrecognized problem among older adults in assisted living (AL) settings. The purpose of this study was to evaluate stakeholder perceptions of using a blended model of depression care that combines essential features of evidence-based collaborative care and older adult outreach for use in AL settings. A descriptive mixed-methods design was used to assess perceptions of the three main components of the depression model: onsite depression care management, staff development activities, and AL nurses as staff resources and liaisons to primary care providers. Quantitative and narrative responses were consistently positive and supportive of depression care approaches. Potential barriers included time constraints for staff and costs for residents. These data provide strong support for further evaluation of the blended depression model. Staff development activities may be implemented independent of the model to enhance depression recognition, assessment, and daily care approaches in AL.

[Res Gerontol Nurs. 2013; 6(2):98-106.]

Abstract

Depression is a common, disabling, and underrecognized problem among older adults in assisted living (AL) settings. The purpose of this study was to evaluate stakeholder perceptions of using a blended model of depression care that combines essential features of evidence-based collaborative care and older adult outreach for use in AL settings. A descriptive mixed-methods design was used to assess perceptions of the three main components of the depression model: onsite depression care management, staff development activities, and AL nurses as staff resources and liaisons to primary care providers. Quantitative and narrative responses were consistently positive and supportive of depression care approaches. Potential barriers included time constraints for staff and costs for residents. These data provide strong support for further evaluation of the blended depression model. Staff development activities may be implemented independent of the model to enhance depression recognition, assessment, and daily care approaches in AL.

[Res Gerontol Nurs. 2013; 6(2):98-106.]

Late-life depression is a large and growing public health problem that will soon be second only to heart disease in terms of global health burden (Chapman & Perry, 2008; Lyness, Yu, Tang, Tu, & Conwell, 2009). Depression is strongly associated with functional impairment and disability in older adults and is both emotionally and financially costly to individuals and society (Lyness et al., 2007; Unutzer et al., 2009). This often-devastating illness is particularly important to consider in assisted living (AL) settings where 1 in 4 older adults (24% to 27%) have clinically significant depression symptoms (Adams & Moon, 2009; Watson et al., 2006).

The importance of recognizing and treating depression symptoms in AL residents is supported by several factors. First, the characteristics of AL residents are highly consistent with known risk factors for major depression, including functional limitations, advanced age, living alone, and presence of clinically significant depression symptoms (Cole, McCusker, Ciampi, & Belzile, 2008; Lyness et al., 2009; van’t Veer-Tazelaar et al., 2008). Second, AL staff often dismiss depression-related symptoms as part of normal aging, instead of recognizing them as a treatable illness (Davison, McCabe, Mellor, Karantzas, & George, 2009). Third, the signs and symptoms of depression—dysphoria; anhedonia; anorexia; insomnia; fatigue; concentration impairment; and feeling helpless, hopeless, or that life is not worth living—may reduce engagement in essential self-care routines that are needed to maintain overall health and tenure in AL. The “cycle of depression” that occurs as depression-related behaviors, thoughts, and feelings interact with social stress and physical health problems often perpetuates distress and dysfunction (IMPACT, 1999) and, in turn, jeopardizes staying in the AL setting. Collectively, these factors suggest that a multicomponent approach to improve depression recognition and provide early interventions may improve health outcomes and increase function (Frederick et al., 2007), thus facilitating older adults’ ability to age in place in their preferred living environment.

The purpose of this article is to describe a newly developed model of care, Depression Treatment for Assisted Living (DT-AL) and the outcomes of a feasibility study designed to evaluate key features of the intervention. Three specific aims were addressed: (a) to determine AL staff and resident perceptions of onsite care manager services, (b) to evaluate depression-focused staff development activities for use in AL settings, and (c) to assess perceptions of using RN leaders as a staff resource and liaison person. Theoretical underpinnings and rationale for the DT-AL model are presented first, followed by description of the mixed-methods study.

Depression Treatment for Assisted Living Model

The multi-component DT-AL model is theoretically linked to depression prevention and goals of reducing functional impairment, disability, and higher overall health care costs that are associated with late-life depression (Lyness et al., 2009; Strine et al., 2009; Unutzer et al., 2009). The model strategically blends two successful evidence-based approaches to depression recognition and care: Improving Mood Providing Access to Collaborative Treatment (IMPACT, Unutzer et al., 2002), a collaborative depression care management model; and Psychogeriatric Assessment and Treatment in City Housing (PATCH, Rabins et al., 2000), an older adult outreach model. The blended DT-AL model builds on and extends care approaches successfully used in IMPACT and PATCH, as shown in Table 1. The three main components of the DT-AL model are briefly described to frame the methods used in the descriptive study.

Key Components of PATCH, IMPACT, and the DT-AL Model

Table 1: Key Components of PATCH, IMPACT, and the DT-AL Model

Enhanced Collaborative Care Management

Collaborative depression care management is a widely recognized evidence-based practice for treating late-life depression in home and primary care settings (Frederick et al., 2007). In DT-AL, the specially trained depression care manager is called an Enhanced Care Manager (known as Care Manager in this article) to improve acceptability to older adults. As in IMPACT, the collaborative care team includes an offsite psychiatrist who consults with the Care Manager about treatment and the AL resident’s regular primary care provider (PCP). In addition, the DT-AL model includes the AL facility RN who acts as the staff resource person and liaison to the PCP, as well as staff development activities for AL staff who provide daily care. The larger circle of collaborators and broader focus on daily interactions is aimed at creating an environment in which depression is viewed as an illness, contributing factors are understood, and all providers share responsibility to help the older adult avert illness, maintain function, and engage in enjoyable, health-promoting activities.

Staff Development

Staff development activities help AL staff not only recognize depression but also help them collaborate with the RN leader and Care Manager to incorporate depression-sensitive approaches and interventions into their daily care routines. Three key issues related to changing daily care practices include: (a) recognizing depression, (b) talking with older adults about depression, and (c) adjusting daily care approaches and interventions to increase function and reduce depression-related problems that are too often “accepted” as being consequences of advanced age and ill health.

RN Staff Resource & Liaison

The third component is unique to DT-AL and involves the RN leader in the AL facility serving as a depression resource person for staff and a liaison to the older adult’s PCP. The goal is to help AL nurses build depression-related skills that endure beyond the intervention. Additional RN role support is provided by the Care Manager as he or she provides depression care services to older adults in the AL facility.

DT-AL Feasibility Study

The year-long descriptive feasibility study was designed to critically review DT-AL components with AL stakeholders before conducting a clinical trial. Materials were reviewed and critiqued related to their acceptability (reaction to the intervention and/or approaches used), practicality (constraints related to time, resources, and commitment), and anticipated implementation issues (Bowen et al., 2009). The relevance and usefulness of the strategies, topics, and approaches were a primary focus. The principal investigator (M.S.) and graduate research assistant (C.H.) developed the evaluation tools/methods, conducted the assessments and interviews, and entered and analyzed the data. The study was approved and monitored by the university’s Institutional Review Board.

Setting and Sample

A convenience sample of AL facilities located in the geographical region surrounding the university was used. Because the goal was to gather different perspectives and views of factors that may affect the DT-AL model, large (60 or more residents), medium (20 to 59 residents), and small (less than 20 residents) AL facilities in rural and urban settings were sought. The sample size of 30 participants (3 RN leaders, 15 additional staff, and 12 residents) was a conservative estimate based on the time frame and financial support available. The RN leader invited the older adults to participate.

Instruments and Data Collection

Staff and resident background forms included age, sex, race/ethnicity, educational level, years living/working in AL settings, and prior depression education (staff). Satisfaction with work (staff) or living in AL (residents) was rated on a scale ranging from 1 (very dissatisfied) to 10 (very satisfied). Paper evaluations were developed to rate features of the three DT-AL components, as described in Table 2. Quantitative items were rated on a 6-point scale where 1 represented a negative value and 6 represented a positive value. Each scale contained definitions and explanations to guide ratings. Open-ended questions encouraged participants to add other ideas or comments and/or to “list the three most important” issues related to selected topics. Semi-structured interviews and discussions were conducted with individuals and small groups.

Depression Treatment for Assisted Living Feasibility Issues and Evaluation Methods

Table 2: Depression Treatment for Assisted Living Feasibility Issues and Evaluation Methods

Procedures

After enrollment, five to eight site visits were made to each AL facility to conduct study activities. Sections of a Staff Resource & Liaison Manual were provided sequentially to RN leaders to allow time for their review and critique. Small group discussions with AL staff and residents were conducted on the last visit. All programs were scheduled at the convenience of staff and were repeated as needed.

Data Entry and Analysis

Numeric and narrative responses to questions were entered on a secure Windows®-based PC using REDCap™ electronic data capture tools (Harris et al., 2009) hosted by the university. Quantitative data were examined using frequency distributions, means, and median scores. Answers to open-ended questions, audiorecorded interviews, and narrative notes were examined using inductive content analysis procedures (Elo & Kyngas, 2007).

Results

Sample

Four AL facilities agreed to participate, including one large (84 residents), two medium-sized (23 and 25 residents), and one small (9 residents) programs. The facilities were located in rural and urban settings (two each). All provided independent housing services in addition to AL services, and one also provided nursing facility care on the same campus.

A total of 18 AL staff participants were enrolled, including 5 RNs, 4 certified medication assistants, 3 certified nursing assistants, 3 universal workers, 2 administrators, and 1 licensed practical nurse (LPN). Additional roles of staff included assistance with housekeeping (n = 7), dietary (n = 6), activity (n = 6), and maintenance (n = 2). Staff participants were 94% women (1 man), White (100%), ages 28 to 65 (median age = 42.2), and had been employed in their current position for 1 to 7 years (median = 2 years). Educational levels included less than high school (6%), high school (33%), and college (1 to 4 years, 61%). Four (22%) reported attending depression education programs prior to the study. Satisfaction with work in AL clustered around anchors of very satisfied (56%) and somewhat satisfied (38%). One person (6%) who indicated being very dissatisfied terminated employment before the second site visit.

Fifteen resident participants were enrolled. Resident participants were primarily women (80%), ages 62 to 96 (median age = 90) who were White (100%) and had lived in AL for 1 to 7 years (median = 3 years). Educational levels included less than high school (33%), high school (20%), college (33%), and graduate degrees (13%). Satisfaction with living in AL ranged from being somewhat satisfied (67%) to very satisfied (33%).

Staff Development Activities

Topic Evaluation. All 18 AL staff completed evaluations. All three topics were given high scores (on the 6-point scale), resulting in means of 5.8 for Depression Recognition, 5.3 for Talking about Depression, and 5.8 for Changing Care Approaches and Interventions. Participants preferred in-person training (mean = 5.8) over CD, DVD, video, or web-based approaches (means ⩽ 4.7). Small group discussions about common problems and real cases were the most popular training approaches (both means = 5.6 versus ⩽4.8 for handouts, case studies, or homework). Supportive educational brochures about depression for residents and families (mean = 5.3) were favored over pocket cards, posters, or web-based resources (means ⩽ 4.7).

Responses to the request for things that are likely to interfere with using approaches to support and assist older adults with depression clustered into two main themes: Perceptions of Resistance among Older Adults and Time Constraints. Perceptions of Resistance among Older Adults was reflected in comments such as: “Most people will not open up to us and talk about depression,” “They may not agree that they are depressed (denial),” “Residents do not want to engage in activities,” and “Them [older adults] not being able to find something enjoyable to do or be active.” The second main theme, Time Constraints, included comments such as: “Not having enough time to always listen to all the tenants’ problems and feelings” and “Time it might take to sit and listen to a person talk about how they feel because you have other things to get done, and also other people to take care of.”

Possible strategies to overcome these challenges clustered into two main themes: Improved Depression-Related Resources and Skills, and Improved Facility Resources. The first theme, Improved Depression-Related Resources and Skills, included statements such as: “A brochure to show the adult what it is and it’s OK to talk,” “Be educated enough to recognize the symptoms of depression,” and “Good advice on what to say.” The second theme, Improved Facility Resources, included statements such as: “More staff” and “Ability to spend more 1:1 [one-to-one] time with residents.”

Program Evaluations. The topic evaluation results guided the development of the three short staff development programs that were implemented and evaluated by AL staff. Each topic received high ratings on items relating to knowledge and care (mean = 4.8 to 6.0). Responses to open-ended questions were similarly positive. Common themes included increased understanding and awareness of depression among residents, the importance of using standardized depression rating scales to quantify and monitor symptoms, and the value of making “simple” adjustments in daily care routines to promote self-care, and social and activity engagement.

Staff Resource & Liaison Manual and Materials

Responses by 5 RN participants reflected a combination of appreciation for the ideas and concerns about time constraints. Table 3 provides item examples. RN role ratings were slightly higher when items were rated for their perceived usefulness (mean = 4.8 to 5.8) versus their feasibility (4.0 to 5.5).

Examples of RN and Care Manager Role Evaluation Itemsa

Table 3: Examples of RN and Care Manager Role Evaluation Items

Enhanced Care Manager Role

Structured small group discussions with AL staff (N = 14) and residents (N = 15) resulted in a large number of positive comments and support for the Care Manager role. Staff supported the provision of onsite depression services. Staff viewed residents as being very private but also noted that having outside health providers was common and unlikely to elicit gossip that would impede service use. All RN leaders reported having good working relationships with PCPs and anticipated that most physicians would cooperate. However, they also acknowledged “It depends on the physician.” Time constraints for staff development activities and the goal of engaging 50% of staff were also a concern.

Resident discussions included a mixture of general statements related to problems with mood, adjusting to AL care, and making friends, as well as thoughts about Care Manager roles. Although residents with depression were not recruited for the discussions, 4 of 15 residents (27%) volunteered information about their personal experiences with depression. Resident participants were supportive of onsite services, such as “This is all going to take place here. We don’t have to go out? Well, I think that would be good!” and “I can see how that would be very beneficial.” While some expressed concern about burdening already busy staff (“Would it generate a lot more paperwork for people who are already overwhelmed by it?”), others considered the assistance part of their caregiver’s job (“They should be doing those things, shouldn’t they? I think it’s part of their job.”) Gossip was accepted as a norm and was not viewed as a barrier to Care Manager services: “What they think, they think. You’re not gonna change their mind. When you get past 80, it don’t matter.” Opinions about their physician’s support of Care Manager services were mixed, as some agreed it was important, and others didn’t think they needed to be involved: “Do you think my doctor would mind if I saw someone of my choosing? Well, I don’t see how he’d have anything to say about it!” The cost of the services was a main concern and was discussed in the light of high costs for AL care, medications, and health care, for example: “My question is whether cost would be the biggest thing. We are already paying as much rent as we want to be paying. We’re all in the same boat!”

Discussion

The DT-AL model has considerable potential to reduce the distress, disability, and costs of late-life depression by taking services to AL—a setting that is both increasingly popular and populated with older adults who experience multiple depression risk factors. The findings indicate that the three main components were acceptable and practical for use in AL and that approaches to care were viewed as relevant and useful. Potential barriers were few and largely revolved around resident concerns about time constraints for staff, service costs, and including the PCP.

An important first observation is that the feedback from the staff development activities indicates AL staff valued gaining depression-related knowledge and skills, particularly related to depression recognition, using standardized scales to quantify symptoms, and making “simple” changes in daily care to promote health. Staff members also valued information about adjusting their communication with older adults who are depressed (e.g., listening, accepting feelings). Both paper ratings of the program and staff interviews conducted 4 months later supported the value of helping staff better interact with residents.

A second important observation is that AL nurses in this study were both supportive of depression care for their residents and willing to assume additional roles to facilitate care and treatment. Their roles in depression care were viewed as both beneficial to resident care (useful) and practical to do in terms of time and resources (feasible). Of note, three RN activities that were top rated for being both useful and feasible for AL nurses may be enacted outside of the DT-AL model: (a) identifying depression-related problems among residents, (b) assessing depression using the PHQ-9 depression scale (Kroenke, Spitzer, & Williams, 2001), and (c) interacting with the PCP about antidepressant medications. Additional daily roles were considered useful, but slightly less feasible, such as helping family members and staff understand, communicate, and intervene with older adults who are depressed. The time needed to support and assist staff is a real-life concern for busy nurses who are often the only RN in the AL setting. As AL moves away from a hospitality model to address the often complex medical conditions of residents, advocacy for diverse RN contributions as a standard component of AL care (Vance, 2008) is essential.

A third important observation was that nurses believed they could gain cooperation with residents’ PCPs related to depression care but were somewhat less certain about the level of support that would be extended for depression-specific care. That finding is understandable considering that adoption of beneficial depression care practices, such as screening or collaborative care, is not widespread in primary care settings (Frederick et al., 2007). Implementation of the DT-AL model, or even traditional depression care in cooperation with PCPs, may rely on nurses taking advocacy and educational roles to promote optimal outcomes for older adults in their care.

Finally, AL staff and residents alike perceived the Care Manager roles as achievable by nurses. The paper ratings and interview data suggested that staff thought older adults would be receptive to care, but they were less certain about whether older adults would cooperate in treatment approaches such as problem-solving therapy or behavioral activation (i.e., pleasant activity scheduling). In contrast, feedback from older adults in the small group interviews suggested that help to solve problems and restore activity levels would be valued. Participants’ personal stories related to the challenges of transitioning to AL care, difficulty re-establishing friendships and enjoyable routines, and experiences with depression underscored possible roles for the Care Manager. Furthermore, the difference between staff perceptions of residents and residents’ self-reports is an important consideration that has been noted in the other late-life depression research (McCabe, Davison, Mellor, & George, 2009; Mellor, Davison, McCabe, & George, 2008). As suggested in the current study and in other studies, attitudes and beliefs among caregivers about older adults’ willingness to recognize depression, talk about their feelings, or participate in treatment may pose serious barriers to helping older adults with depression. Superior outcomes are consistently achieved when providers talk openly about depression and older adults’ preferences for depression treatment (Unutzer et al., 2002).

Limitations

Like most small studies, this one has several limitations. First, the facilities and participants were volunteers. Other facilities may not have the same level of interest and/or commitment to changing depression care practices. Second, the small sample and restricted geographical region provides a limited view. However, characteristics of staff and resident samples are highly consistent with reports about AL throughout the state and nation (National Center for Assisted Living [NCAL], 2009). Although staff development activities were implemented during the study, Care Manager roles were not. Perceptions of the RN and Care Manager roles were gathered, but implementation-related issues will need to be assessed further in the next study.

Other potential limitations relate to the model itself. DT-AL is designed for use with older adults who have sufficient cognitive capacity to self-report depression symptoms and use problem-solving activities to restore function. The model also relies on having an available and willing RN leader in the AL facility. Given that only 30% of states have AL rules requiring RN services (NCAL, 2011), further adaptations may be needed to fit the model to state-driven or individual facility policies.

Conclusion

The findings of this study suggest that AL nurses and staff caregivers are both aware of depression among residents and receptive to assistance. Staff development activities may be used independent of the DT-AL model to enhance depression recognition, promote use of standardized scales to detect and monitor symptoms, and encourage adjustments in daily routines to promote health-related activities among older adults. Our findings also provide an important foundation for further evaluation of the DT-AL as an innovative approach to depression care in AL settings.

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Key Components of PATCH, IMPACT, and the DT-AL Model

Service Component/Feature PATCH IMPACT DT-AL
Care coordination team
  Care Manager X X X
  Consulting psychiatrist X X X
  Primary care provider X X
  RN leader in AL facility X
  AL staff members X
Care Manager services
  Comprehensive assessment X X X
  Treatment plan development, implementation, and review X X X
  Consultation with psychiatrist X X X
  Consultation with primary care provider X X
  Time-limited treatment X X
  Depression relapse plan X X
  Referral for ongoing care X X
  Staff training/development X X
  Nurse resource-liaison training and support X
Staff training/development focus
  Recognize mental health problem/depression X X
  Refer for evaluation and treatment X X
  Assess depression symptoms X
  Promote communication and talking about feelings X
  Adjust daily routines and promote self-care X
  Encourage activity participation X
RN Staff Resource & Liaison role
  Conduct depression screenings and assessments X
  Make referrals to Care Manager for treatment X
  Assist staff to promote “antidepressant” activities X
  Interact with primary care provider related to care recommendations X

Depression Treatment for Assisted Living Feasibility Issues and Evaluation Methods

Model Component: Issues Evaluation Approach/Scale Names and Descriptions
Staff development activities:

Topic relevance to AL care

Preferred training method, content, format, length

Facility-related barriers

Staff motivation/interest

Paper evaluations:

Topic Evaluation: 3 topic items, 14 training methods items, 2 open-ended questions

Part 1, Depression Recognition: 20 knowledge/care items, 5 training methods items, 4 open-ended questions

Part 2, Talking about Depression: 24 knowledge/care items, 5 training methods items, 4 open-ended questions

Part 3, Changing Care Approaches and Interventions: 26 knowledge/care items, 5 training methods items, 4 open-ended questions

Training trial with small groups of AL staff
RN Staff Resource & Liaison role:

Usefulness to RN leader

Practicality for RN leader

Acceptability to primary care providers

Resource Manual format, content

Paper evaluations:

Staff Resource & Liaison Role Evaluation: 20 role items rated for both usefulness and feasibility, 2 open-ended questions

Primary Care Provider Involvement Evaluation: 16 role items, 6 open-ended questions

Staff Resource & Liaison Manual Evaluation: 8 items (one for each section) rated for understandability, usefulness, and right amount of material; 5 open-ended questions

Discussions with RN leaders
Enhanced Care Manager roles:

Acceptability to RN leaders and staff

Acceptability to AL residents

Perceived barriers

Paper evaluation:

Enhanced Care Manager Role Evaluation: 32 older adult care/treatment items, 9 staff development items, 2 open-ended questions

Small group discussions with (a) RN leaders and AL staff, and (b) AL residents

Examples of RN and Care Manager Role Evaluation Itemsa

Mean (SD) Mean (SD)
Staff Resource & Liaison Role Evaluation (N = 5) Usefulb Feasibleb
Identifying depression-related problems among residents 5.8 (0.4) 5.4 (0.5)
Assessing depression using the PHQ-9 depression scale 5.6 (0.9) 5.4 (0.5)
Sending Care Manager reports to the primary care provider 5.6 (0.5) 5.2 (0.8)
Helping AL staff identify “antidepressant” activities 5.4 (0.5) 4.8 (1.3)
Helping daily staff communicate with depressed older adults 5.2 (0.8) 4.6 (2.0)
Helping daily staff use depression-related interventions 5.2 (0.8) 4.0 (1.8)
Helping family members understand depression as an illness 5.0 (1.0) 4.6 (1.1)
Helping residents understand depression as an illness 5.0 (1.0) 4.2 (0.8)
Primary Care Provider Involvement Evaluation (N = 5) Likelihoodc
Reads care notes faxed by the RN leader regarding resident’s care and treatment 5.0 (0.8)
Addresses contributing problems (e.g., pain relief) when the RN leader or resident asks for help 5.0 (0.8)
Uses Care Manager’s or consulting psychiatrist’s recommendations to prescribe or change antidepressant medications 4.3 (1.0)
Supports the RN leader and/or AL resident related to depression identification and treatment 4.3 (1.5)
Enhanced Care Manager Role Evaluation (N = 5) Feasibled
Older adult care/treatment approaches and interventions (32 items)
  Getting the RN leader to fax notes to the primary care provider 6.0 (0.0)
  Making referrals for continuing care if needed 5.5 (0.6)
  Getting the resident to identify pleasant activities 5.0 (0.8)
  Getting the resident to engage in pleasant activities 4.0 (0.8)
  Getting the resident to record how often activities are done 3.3 (1.2)
  Getting the resident to identify problems for problem-solving therapy 3.0 (0.8)
Assisted living staff interactions and assistance (9 items)
  Getting the RN leader and staff to identify residents with depression symptoms 5.8 (0.5)
  Training staff about depression and its treatment 5.5 (0.6)
  Getting staff to encourage activity involvement 4.8 (1.0)
  Getting at least 50% of staff to attend staff educational programs 3.3 (1.5)
Authors

Dr. Smith is Assistant Professor, and Ms. Haedtke is a doctoral student, The University of Iowa College of Nursing, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was supported by a grant from The University of Iowa College of Nursing John A. Hartford Center for Geriatric Nursing Excellence. The authors thank Jurgen Unutzer, Diane Powers, and others at the IMPACT Coordinating Center for generously allowing them to include IMPACT information and treatment protocols in the depression treatment model.

Address correspondence to Marianne Smith, PhD, RN, Assistant Professor, The University of Iowa College of Nursing, 50 Newton Road, Iowa City, IA 52242; e-mail: marianne-smith@uiowa.edu.

Received: May 21, 2012
Accepted: December 18, 2012
Posted Online: January 22, 2013

10.3928/19404921-20130114-01

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