Research in Gerontological Nursing

Featured Intervention Study 

Decreasing Social Isolation in Older Adults: Effects of an Empowerment Intervention Offered Through the CARELINK Program

Nicholas R. Nicholson, PhD, MPH, RN, PHCNS-BC; Juliette Shellman, PhD, APHN-BC

Abstract

Older adults reporting social isolation are at increased risk for numerous negative health outcomes, including depressive symptoms, decreased quality of life, and cardiovascular disease. The purpose of this study was to test the effects of a university student model of care intervention offered through the CARELINK program on social isolation in a sample of community-dwelling older adults (N = 56). Older adults in the comparison group, who had not yet received the CARELINK program, were nearly 12 times more likely to be socially isolated. Results indicate the empowerment intervention offered through the CARELINK program had positive effects on reducing social isolation in older adults. The CARELINK program has important implications for nursing as it provides an uncomplicated and inexpensive intervention to decrease social isolation for older adults in the community. Given the sample selection limitation in this study, a randomized controlled trial is warranted. Future research should examine specific aspects of the CARELINK program and the amount each aspect affects social isolation.

[Res Gerontol Nurs. 2013; 6(2):89–97.]

Abstract

Older adults reporting social isolation are at increased risk for numerous negative health outcomes, including depressive symptoms, decreased quality of life, and cardiovascular disease. The purpose of this study was to test the effects of a university student model of care intervention offered through the CARELINK program on social isolation in a sample of community-dwelling older adults (N = 56). Older adults in the comparison group, who had not yet received the CARELINK program, were nearly 12 times more likely to be socially isolated. Results indicate the empowerment intervention offered through the CARELINK program had positive effects on reducing social isolation in older adults. The CARELINK program has important implications for nursing as it provides an uncomplicated and inexpensive intervention to decrease social isolation for older adults in the community. Given the sample selection limitation in this study, a randomized controlled trial is warranted. Future research should examine specific aspects of the CARELINK program and the amount each aspect affects social isolation.

[Res Gerontol Nurs. 2013; 6(2):89–97.]

Social isolation accounts for approximately half of all mortality in the United States (Smedley & Syme, 2001). Socially isolated older adults are at increased risk for negative health outcomes including cardiovascular risk, decreased quality of life, and all-cause mortality (Berkman, 1995; Brummett et al., 2001; Gallicchio, Hoffman, & Helzlsouer, 2007). It is projected that the number of adults 65 and older will double by 2040 (U.S. Census Bureau, 2000). As the number of older adults increases (U.S. Administration on Aging, 2009), social and behavioral factors such as social isolation will affect a significantly larger proportion of society. This has major implications for both quality of life and cost of providing health care to the older adult population.

Research has shown that several factors contribute to social isolation in older adults. For example, studies have shown marital status, self-report of health, living alone, decline in functional status, depressive symptoms, and time alone are risk factors for social isolation in this age group (Cohen-Mansfield, 2007; Theeke, 2009). Although risk factors have been identified and evidence demonstrates negative health consequences related to social isolation, the prevalence of social isolation remains significant and is likely to increase in the future. Estimates of adults 65 and older who report social isolation was as high as 35%, with a range of 10% to 35% (Smith & Hirdes, 2009; Tremethick, 2001). Cost-effective, theory-based interventions to reduce the risks associated with social isolation are warranted.

Background

Social Isolation

Social isolation is defined as a “disengagement from social ties, institutional connections or community participation” (Seeman, 1996, p. 442). Social isolation is also characterized by a lack of a support system or a small or nonexistent social network. Social networks are an integral part of the health and well-being of older adults.

Research has demonstrated that social networks have an effect on one’s health status (Berkman & Syme, 1979; Kaplan et al., 1988). Socially isolated individuals have two to four times the risk of all-cause mortality compared with those who have more friends, relatives, and neighbors (Eng, Rimm, Fitzmaurice, & Kawachi, 2002). It has been suggested that social aspects of health may have a serious impact on mortality (Berkman & Syme, 1979), physical health (McAuley et al., 2000), and mental health (Holahan & Holahan, 1987).

Social isolation has been shown to increase the risk of physical health problems, which include cardiovascular disease (Berkman, 1982; Cohen, 1988; Kaplan et al., 1988), coronary artery disease (Brummett et al., 2001; Sorkin, Rook, & Lu, 2002), poor health outcomes after breast cancer (Michael, Berkman, Colditz, Holmes, & Kawachi, 2002), as well as the common cold (Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997). Other negative outcomes of social isolation include increased risk of behavioral, psychosocial, and cognitive problems (Bassuk, Glass, & Berkman, 1999; Fratiglioni, Wang, Ericsson, Maytan, & Winblad, 2000). Individuals who are identified as socially isolated are more likely to engage in risky behaviors, such as smoking, drinking alcohol, and having a sedentary lifestyle (Eng et al., 2002; Hanson, 1994). Men with moderately low social ties had twice the mortality from accidents or suicide as those who reported more social ties (Eng et al., 2002). Social isolation also decreases cognitive function in adults (Bassuk et al., 1999; Fratiglioni et al., 2000).

Interventions to Address Social Isolation

The literature lacks reports of effective interventions to mitigate social isolation (Cattan & White, 1998; Cattan, White, Bond, & Learmouth, 2005; Findlay, 2003). Friendly-visitor programs have been the focus of many intervention programs attempting to decrease social isolation (Cattan et al., 2005). Findlay (2003), who examined the effectiveness of social isolation interventions, found scant evidence to support successful programs.

Interventions such as social cognitive training, support groups, social skills training, reminiscence groups, and computer interventions have been tested to reduce social isolation in older adults (Hill, Weinert, & Cudney, 2006; Fokkema & Knipscheer, 2007; Stewart, Craig, MacPherson, & Alexander, 2001). In a review of studies testing loneliness and social isolation interventions between 1970 and 2002, Catten et al. (2005) found interventions that included specific activities and education modules were most effective. Although group interventions, such as reminiscence, social support groups, and social cognitive training, have shown slight decreases in social isolation, barriers such as access and cost prevent these interventions from reaching the most vulnerable homebound older adults. These data, in addition to a lack of successful interventions to decrease social isolation, make it important to develop and test new strategies to reach the vulnerable homebound population in a cost-effective manner. One such approach is the use of nursing students to deliver an intervention specifically aimed at decreasing loneliness and social isolation in community-dwelling older adults. The CARELINK program represents a case example involving that type of intervention.

Novel Approach Toward Mitigating Social Isolation

One approach to mitigate negative health outcomes resulting from social isolation is to harness the power of both academic and community resources toward the care of older adults. University-community partnerships are collaborative programs aimed at finding ways to provide the best possible care to clients, while providing excellent clinical experiences for students at little or no cost (Goodrow et al., 2001; Huang, 2002). CARELINK is one example of a university-community partnership that uses nursing students to deliver health promotion, chronic illness monitoring, and a number of other nursing-related activities to community-dwelling older adults at no cost to the older adult. At the heart of the program is the care delivered by senior nursing students to older adults during the students’ community health clinical experience. Under the supervision of their instructor and an agency representative, students provide home-based activities to patients who are referred from visiting nurses once they are no longer eligible for compensated services.

The foundation of the CARELINK program is the Partners in Caring model (Bernal, Shellman, & Reid, 2004), which is composed of three basic constructs: (a) open communication system, (b) culture of caring, and (c) knowledge of the community to foster the partnership between the older adults and the university students. These concepts and approach to program development are described elsewhere (Bernal et al., 2004).

CARELINK and Social Isolation

In the CARELINK program, students, in partnership with older adults, use relationship-building techniques (e.g., reminiscence) to promote a culture of caring that fosters open communication and enables students to identify social isolation in their clients. For example, once social isolation is identified, nursing students are able to provide resources to the clients to move toward the goal of renewed socialization. Students attempt to introduce new approaches that may help older adults connect with others. It is through the focus on social aspects of the older adult’s health that the CARELINK program stimulates increased social integration. Pilot studies have shown the CARELINK program to be effective in decreasing falls and lowering systolic and diastolic blood pressure (Clemmens, Nicholson, & Hu, 2006; Kinabrew, Armack, Spector, Miniter, & Shellman, 2004). However, no known studies have examined the effects of the program on social isolation. Therefore, the purpose of this study was to test the effects of a university-student model of care intervention on social isolation in a sample of older adults.

Method

Design and Hypotheses

A two-group, posttest-only design (Shadish, Cook, & Campbell, 2002) was used to test the hypothesis that older adults in the CARELINK program who receive student visits will have significantly less social isolation when compared with those who have not yet had any visits. A second hypothesis to determine whether participation in the CARELINK program predicts lower levels of social isolation while controlling for age, sex, marital status, race, and length of time in CARELINK was also tested.

Setting and Sample

This study was conducted between September 2004 and January 2005 in a mid-sized urban community in the northeastern United States that has a large population of retired blue-collar workers who live in their own homes or apartments. Inclusion criteria were: (a) age 65 or older, (b) score of at least 24 on the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975); and (c) English speaking. This study was approved for human subject protection under the University’s Institutional Review Board review process.

Participants were told about the study by their care provider, and those who expressed interest were contacted and informed of the study via telephone. If the older adult expressed an interest in participating in the study, the data collector met with the individual at home. When all questions regarding participation in the study were answered and written informed consent was obtained, the instruments were administered verbally by the data collector. The intervention group was drawn from the sample of clients currently enrolled in the CARELINK program who were randomly selected to be in the study. The comparison group was a convenience sample composed of all new admissions to the CARELINK program who had not yet received any home visits from students. This sampling method was chosen to compare participants who had not previously received CARELINK with those receiving the intervention. A convenience sample was used for the comparison group in the interest of time due to the low number of new admissions received during the time period of this study (Figure).

Intervention flowchart for the CARELINK program.

Figure. Intervention flowchart for the CARELINK program.

Instruments

A general demographic questionnaire was developed consisting of five demographic items, seven health items, and six items related to possible antecedents of loneliness and social isolation derived from the literature. The Lubben Social Network Scale (LSNS, Lubben, 1988; Lubben & Gironda, 2003) was used to assess participants’ social isolation status. The LSNS is an 18-item questionnaire designed for use with older adults. It contains three equally weighted subscales with six questions each that address participants’ social network of family, friends, and neighbors. The LSNS takes approximately 15 minutes to administer. Each question has a score range of 0 to 5, for a total score of 0 to 90. The total score indicates whether a participant is socially isolated or at high, moderate, or low risk for social isolation. The scoring of the total LSNS is divided into quartiles where the lowest quartile is considered socially isolated. The LSNS has demonstrated effective reliability with a Cronbach’s alpha coefficient of 0.82 for the full scale.

The CARELINK Program

Students in the CARELINK program visit clients every 2 weeks for 4 months. The length of the visit is 1 hour, except for the admission visit, which is 2 hours. During their visits, nursing students conduct physical and psychosocial assessments and create individual nursing care plans based on the clients’ specific needs. At the end of the clinical day, students report their findings and discuss them with an onsite instructor and agency staff. Social isolation is often identified as one of the key issues for the older adults. In response to this need, a community health graduate student, in collaboration with agency staff, developed an intervention to decrease social isolation in community-dwelling older adults. This intervention included an inservice session and structured home visits focusing on assessment and management of social isolation.

Empowerment Intervention

CARELINK students participated in an inservice session for the intervention entitled Empowering Older Adults through Students: Decreasing Social Isolation. This intervention was designed to provide important, straightforward, and easy-to-understand information to students about social isolation (Figure). A variety of teaching methods, such as small group participation, active learning activities, lecture, role-play. and case study, were used to provide maximum learning efficiency by considering the different learning styles of the students. In addition, a resource guide that included general steps for a visit, focusing of social factors, social resources available to older adults, and an outline of the negative health consequences of social isolation, was provided to students to guide them through their home visits. Finally, pretests and posttests were administered to the students to demonstrate effectiveness and comprehension of the social isolation training program.

Delivery of the Intervention

After the students were trained in the empowerment intervention, they were assigned five clients whom they would visit every other week to ensure consistency in delivery of the intervention. The first visit included an extended time of introduction between the older adult and student to formulate social goals for the 16-week period. The social goals serve as a focus of discussion during coaching efforts. Students were instructed to spend 2 hours with each participant to focus on learning about the participant’s background and various social aspects of his or her life in order to build a foundation of trust for future visits.

Each subsequent visit, 1 hour in length, focused on the issues of social isolation, building on the trust and bonding formalized during the initial visit. The intervention was designed to provide the older adult with a long enough period of time to develop trust in sharing their feelings of social isolation. By sharing these feelings, the student could provide emotional support and develop feelings of stronger attachment and solidarity. This, in turn, helped the older adult determine ways to address his or her own problems in the form of empowerment, as opposed to dependence.

Each of the visits used a variety of techniques including (a) reminiscence, (b) exercise-talk discussions, (c) goal-oriented, social engagement-directed discussions, (d) coaching, and (e) modeling. In reminiscence therapy, the older adults discussed positive aspects of their lives when they believed they were more socially integrated. The goal of this technique was to allow the person to remember the value and relative ease of social engagement. With encouragement from the student, the goal is to empower the older adults to take steps to engage socially as they did in the past. Exercise talk is when the student and older adult perform physical therapy goal-oriented exercise while discussing social aspects of health. The idea was to perform a common activity (i.e., exercise) to focus attention, so the social discussion would flow naturally. In goal-oriented, social engagement-directed discussion, the student and older adult sit face to face and discuss social isolation. Speaking directly about these psychosocial issues may motivate the older adult to seek new solutions. Participants had the ability to influence the interaction in whatever manner they chose. Fostering open communication between the student and older adult created a comfortable atmosphere for the older adults to discuss their difficult social issues. The ability to alter the plan of care for each visit gave the older adults a feeling of directing the visit, which supported empowerment. Coaching was focused on providing constant encouragement to achieve social integration and the older adult’s specific goals. As older adults achieved or even attempted to achieve their social goals, they were encouraged to continue and given positive feedback. Modeling was focused on sharing personal experiences related to appropriate social behavior, with the goal of encouraging the older adults to emulate those social experiences.

Intervention fidelity was monitored throughout the study with weekly time cards, co-visits, and review of the social goals and care plans. Each student met with the principal investigator (PI, N.R.N.) weekly to hand in their time card and discuss the ongoing care plan of his or her assigned older adult. In these meetings, the PI could ensure each technique was undertaken by the student in a consistent manner. The social goals developed by the student-older adult dyad were reviewed at the first weekly meeting to ensure the goals were realistic and appropriate. The goals were reviewed at each weekly meeting to monitor accomplishments or setbacks. Finally, each student had a co-visit with the PI to make certain each student was using the techniques appropriately.

Data Analysis

Data were analyzed using SAS version 9.2. Data were entered and cleaned prior to statistical testing. An initial chi-square analysis was performed to determine whether differences existed between the intervention and comparison groups on the variables of being socially isolated. After this determination was made, a logistic regression was performed to control for likely confounding variables. For the logistic regression modeling, the dependent variables related to social isolation were treated as discrete variables: non-socially isolated (LSNS score = 23 or above) or socially isolated (LSNS score = 22 or less). This cut-off score for social isolation was determined through examination of the distribution of scores, where the lowest quartile was considered socially isolated (Lubben, 1988; Lubben & Gironda, 2003). Data were found to be an appropriate fit for the model using the Homer-Lemeshow goodness-of-fit test. To arrive at the best fitting model, the literature is the priority, but the lowest log likelihood (–2L) score was used to make final decisions on model fit. Other pertinent model-fit scores, including Akaike information criterion (AIC) and Schwarz criterion (SC), were examined as well.

Results

Demographic Characteristics

Demographic characteristics of the sample are summarized in Table 1. The mean age of the sample was 82.6 (SD = 8.7 years). It was found that 17.9% of the sample was in the 65-to-74 age category, 30.4% were in the 75-to-84 category, and 51.8% were in the 85 and older category. Sex was not equally distributed, with women making up 73.2% of the sample. The majority of participants reported their race as White, non-Hispanic (91.1%), followed by Asian/Pacific Islander (7.1%). The largest percentage of participants had a marital status of widowed (51.8%), following by married (33.9%).

Demographic Characteristics of the Sample

Table 1: Demographic Characteristics of the Sample

The most common comorbid chronic conditions in the sample were hypertension, arthritis, and heart disease (Table 1). Since a convenience sampling design was employed, a chi-square, Mann-Whitney U, or t test was used, depending on the level of measurement of the variable. These statistical tests were conducted to determine whether any differences existed in demographic characteristics between the interventions and comparison groups. No significant differences were found between the groups based on available demographic and health variables, including age, sex, race, marital status, and number of chronic conditions.

Effects of the CARELINK Program

Chi-square analysis of the intervention and comparison groups demonstrated a statistically significant difference in social isolation. Of the participants who were not socially isolated, 65.85% were in the intervention group and only 34.15% were in the comparison group. Likewise, of those who were socially isolated, 20% were in the intervention group and 80% were in the comparison group. A significant difference was found in social isolation between those who were and were not in the intervention group, χ2 = 9.28, df = 1, p = 0.002. Those who were in the intervention group were less likely to be socially isolated compared with those in the comparison group.

Logistic regression was used to analyze the impact of the empowerment intervention offered through the CARELINK program on social isolation. Backward-selection technique was used to determine the best fitting model. When examining model-fit statistics, this model had an AIC = 64.24, SC = 80.44, and −2L = 48.25. In the final model, older adults in the comparison group were 11.63 (95% confidence interval [2.01, 67.45]) times more likely to be socially isolated than those in the intervention group, while controlling for age, sex, race, marital status, and time in CARELINK (Table 2).

Logistic Regression Model for Social Isolation

Table 2: Logistic Regression Model for Social Isolation

Discussion

Results from this study show that the empowerment intervention offered through the CARELINK program affects levels of social isolation in older adults. The strong association between the group of older adults in the CARELINK program and lower levels of social isolation suggests this program is an effective intervention to maintain low levels of social isolation or decrease levels of social isolation in older adults. These findings differ from an experimental study conducted by Van Rossum et al. (1993) to test the effects of preventive home visits to older adults. Results from that study showed no significant differences between the groups with respect to social isolation. One explanation for the conflicting results could be that the intervention in Van Rossum et al.’s (1993) study included only four visits per year over a 3-year period, with general discussion about health topics from a public health nurse. The CARELINK program included visits every other week continually over a 4-month period, with specific training regarding assessment and management of social isolation.

The literature suggests that decreasing social isolation in older adults should involve social cognitive training in groups (Masi, Chen, Hawkley, & Cacioppo, 2011). Although there is evidence that group interventions may be effective in decreasing social isolation, group interventions are less feasible for the most vulnerable older adult population—those who are homebound and have chronic illness. Cost-effective, innovative, interdisciplinary interventions to reach this population are needed to reduce their social isolation.

The structure of the empowerment intervention offered through the CARELINK program is such that the focus of the health-related visits is on social factors, such as social isolation. The nursing students who visit the older adults are not constrained by outside payer sources that may restrict the length of visit, type of visit, or the interventions performed with the client during the visit. Based on the central constructs of the CARELINK program, maintaining an open communication system and creating a culture of caring, as well as a feeling of bonding and interpersonal connection between the older adults and students, were fostered to focus on aspects of their lives that the older adults feel are most important, instead of ones that are reimbursable (Bernal et al., 2004). The bond formed between the student and the older adult may be such that the older adult will be motivated to try new health promotion activities, such as interacting socially with friends or neighbors and getting in touch with estranged family members. Other studies have suggested that the bond between student and client creates positive health outcomes for the client due to the trusting relationship that is formed (Heineken & McCoy, 2000).

Health care providers caring for community-dwelling older adults often recognize that social isolation is a significant issue in their clients’ lives; yet, there are few interventions that show promise in reducing it (Findlay, 2003). Often, health care providers are pressed for time and unable to help their clients in the community with effective strategies to reduce social isolation. A community-university partnership such as CARELINK is a cost-effective program that, if made available, could help clients tremendously.

Results from this study suggest that the CARELINK program shows promise in reducing or potentially preventing social isolation. This model of consistent visits made by the same individual—an informed and dedicated health care professional—and focusing on social aspects of health should be further tested. Developing partnerships between community agencies and universities in which students provide services to older adults is one way to decrease or prevent social isolation. Providing education that focuses on the assessment and management of social isolation through a variety of techniques, as described in this article, are key components to the intervention.

Limitations

Limitations of this study include the relatively small sample, composed of primarily White non-Hispanic participants. Lack of diversity in the sample may limit the generalizability of the results to other populations. Nursing students were unblinded during both data collection and administration of the intervention. This could have led to increased effort among the nursing students to work toward decreasing social isolation in the intervention group. Alternatively, the students may have put in less effort for those older adults known to be in the comparison group. Taking these factors into account, this could have led to a bias accentuating the effectiveness of the CARELINK program versus usual care.

The use of two sampling methods could be a limitation in that the comparison group, which was a convenience sample, could be an accurate representation of the CARELINK population, whereas the intervention group, which was randomly selected, may not be representative of the CARELINK population. However, differences between the intervention and comparison groups regarding demographic and clinical characteristics were tested, and no significant differences were found. The decision to use a convenience sample for the comparison group was based on the anticipated time needed to recruit a sufficient sample for randomization. Similarly, the decision to use a posttest-only design was influenced by the limited time we had access to the trained nursing students, as well as the amount of time we were allowed access to the older adults. This design is a limitation and may not properly account for unknown and untested baseline differences between the two groups. Therefore, the results should be interpreted with caution.

Conclusion

The CARELINK program is designed to focus on important psychosocial issues among older adults, such as social isolation. The overall goal of this intervention study was to test the effects of a university-community partnership model of care intervention on social isolation in a sample of community-dwelling older adults. The empowerment intervention offered through the CARELINK program was found to be successful in reducing social isolation in this sample of older adults. Using regular visits focused on assessment of social isolation along with identification and mitigation of psychosocial issues may provide a model for design of future intervention projects.

Findings from this study will inform the next step of social isolation research to evaluate the effectiveness of the CARELINK program in decreasing social isolation using a randomized experimental design with a larger, more diverse sample to increase generalizability. Furthermore, understanding which specific aspects of the CARELINK program may affect social isolation is a crucial next step.

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Demographic Characteristics of the Sample

Characteristic Comparison Group (n = 28) Intervention Group (n = 28) Total (N = 56) p Value
Age in years, mean (SD) 82.9 (9.7) 82.3 (7.9) 82.6 (8.7) 0.81
Age categories 0.62
  65 to 74 6 (21.4) 4 (14.3) 10 (17.9)
  75 to 84 7 (25) 10 (35.7) 17 (30.4)
  85 and older 15 (53.6) 14 (50) 29 (51.8)
Women, n (%) 20 (71.4) 21 (75) 41 (73.2) 0.53
Race, n (%) 0.09
  White non-Hispanic 26 (92.8) 25 (89.3) 51 (91.1)
  Asian/Pacific Islander 2 (7.1) 2 (7.1) 4 (7.1)
  Black, non-Hispanic 0 (0) 1 (3.6) 1 (1.8)
Marital status, n (%) 0.10
  Widowed 15 (53.6) 14 (50) 29 (51.8)
  Married 8 (28.6) 11 (39.3) 19 (33.9)
  Single 5 (17.9) 3 (10.7) 8 (14.3)
Chronic conditionsa, n (%)
  Hypertension 20 (71.4) 24 (85.7) 44 (78.6) 0.41
  Arthritis 19 (67.9) 20 (71.4) 39 (69.6) 0.51
  Heart disease 15 (53.6) 14 (50) 29 (51.8) 0.53
  Depression 13 (46.4) 11 (39.3) 24 (42.9) 0.31
  Diabetes 9 (32.1) 9 (32.1) 18 (32.1) 0.43
  Cancer 5 (17.8) 7 (25) 12 (21.4) 0.71
  Cerebral vascular accident 6 (21.4) 5 (17.9) 11 (19.6) 0.45
  Incontinence 4 (14.3) 8 (28.6) 12 (21.4) 0.31

Logistic Regression Model for Social Isolation

Variable B Standard Error Wald df p Value Odds Ratio 95% Confidence Interval
Comparison group 2.45 0.89 7.48 1 0.006 11.63 [2.01, 67.45]
Intervention group (reference group)
Authors

Dr. Nicholson is Assistant Professor, Quinnipiac University School of Nursing, Hamden, and Dr. Shellman is Associate Professor, University of Connecticut School of Nursing, Storrs, Connecticut.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Dr. Nicholson was supported by a training grant from the National Institute on Aging (T32AG1934). The authors thank Henrietta Bernal, Deborah McDonald, Richard Fortinsky, Karen Reid, and the University of Connecticut nursing students for their help in putting together this project.

Address correspondence to Nicholas R. Nicholson, Jr., PhD, MPH, RN, PHCNS-BC, Assistant Professor, Quinnipiac University School of Nursing, 275 Mount Carmel Avenue, N1-HSC, Hamden, CT 06518; e-mail: nicholas.nicholson@quinnipiac.edu.

Received: November 16, 2011
Accepted: July 18, 2012
Posted Online: January 17, 2013

10.3928/19404921-20130110-01

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