Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

A Grounded Theory Investigation Into Sophomore Students' Recall of Depression During Their Freshman Year in College: A Pilot Study

Julie M. Brandy, PhD, RN, FNP-BC, CNE; Theresa A. Kessler, PhD, RN, ACNS-BC, CNE; Christina H. Grabarek, PhD, NCSP, HSPP

Abstract

Using a grounded theory approach, the current descriptive qualitative design was conducted with sophomore students to understand the meaning participants gave their freshman experiences with depression. Twelve participants were recruited using scripted class announcements across campus. After informed consent, interviews began with the question: What was the experience of your freshman year in college? All interviews were completed with the primary investigator and transcribed verbatim. Interviews were analyzed using constant comparative methodology. Data collection continued until saturation was achieved. Four major categories emerged, including the category of symptoms and emotions. This category included the subcategories expressions of stress, changes in eating habits, sleep issues, and procrastination. Descriptive examples of each were found throughout the interview data. With greater understanding of living with depression as a college freshman, health care and college student affairs professionals will have additional evidence to guide their practices. [Journal of Psychosocial Nursing and Mental Health Services, 56(9),44–50.]

Abstract

Using a grounded theory approach, the current descriptive qualitative design was conducted with sophomore students to understand the meaning participants gave their freshman experiences with depression. Twelve participants were recruited using scripted class announcements across campus. After informed consent, interviews began with the question: What was the experience of your freshman year in college? All interviews were completed with the primary investigator and transcribed verbatim. Interviews were analyzed using constant comparative methodology. Data collection continued until saturation was achieved. Four major categories emerged, including the category of symptoms and emotions. This category included the subcategories expressions of stress, changes in eating habits, sleep issues, and procrastination. Descriptive examples of each were found throughout the interview data. With greater understanding of living with depression as a college freshman, health care and college student affairs professionals will have additional evidence to guide their practices. [Journal of Psychosocial Nursing and Mental Health Services, 56(9),44–50.]

Attending a university for the first time and adjusting to college life can be a stressful experience for college-age students. As students transition from adolescence to adulthood, they must effectively adjust to unfamiliar university life, or they may be vulnerable to negative emotional symptoms. Increased stress related to the first year of college has been associated with adjustment issues and depressive symptomology. Therefore, it is important to understand adjustment to university life and the unique experience of college freshmen living with depression.

Of concern is the increased incidence of depressive symptoms in college students and the ways in which depressive symptoms might impact college students' transition into adulthood. In a survey of university counseling center directors, 91.6% of respondents reported that they observed an increase in the number of students experiencing psychological problems in recent years (Blanco et al., 2008). In a large nationwide survey conducted by the American College Health Association (ACHA; 2015) (N = 74,438), 65.1% of undergraduate student respondents reported “feeling very sad” in the past 12 months, and 35.3% reported “feeling so depressed it was difficult to function” (p. 32). Despite the alarming incidence of negative emotional symptoms experienced by college students, only 13.2% reported receiving professional treatment for depression within the past 12 months (ACHA, 2015). This percentage is concerning because unrecognized and untreated depressive symptoms can lead to negative events in the lives of college students. The consequences of unrecognized and untreated depressive symptoms may include high-risk behaviors, physical health problems, and suicidal ideation (Reeves & Riddle, 2014).

Although depression as experienced exclusively during the freshman year of college is an important construct to study, little research is available about this singular year. A longitudinal panel design comparing freshman college students at the beginning and end of their first year found that the experience might cause psychological distress and physical symptoms (Pritchard, Wilson, & Yamnitz, 2007). In another study focused on first-year college students (N = 188), an alarming 48% were found to experience depressive symptomology, as evidenced by scores of ≥16 on the Centers for Epidemiologic Studies Depression Scale (Brandy, Penckofer, Solari-Twadell, & Velsor-Friedrich, 2015). Similarly, at a college in Belgium, researchers reported that approximately 33% of freshmen had emotional and behavioral problems, with 23.7% reporting internalizing problems, including depressive symptoms. Students with mental health problems had a decrease of 0.2 to 0.3 in grade point average at the end of the academic year compared to those without mental health problems (Bruffaerts et al., 2018).

A number of studies have examined depression in undergraduates enrolled in introductory courses, but not exclusively students in the freshman year. Researchers found that 19% of undergraduates in an introductory course reported mild levels of depression, 14.5% reported moderate to severe depression, and approximately 29% experienced clinically significant depression and insomnia (Gress-Smith, Roubinov, Andreotti, Compas, & Luecken, 2015). In another study of students in introductory courses, stress was positively related to depression (Dixon & Robinson Kurpius, 2008). The combination of self-esteem, feeling as if one mattered, and gender enhanced the influence of stress on depression. Within the same study, female students reported greater levels of depression and academic stress than male students.

As early as 1993, undergraduate college students in introductory courses experienced depression with symptoms that were consistent with criteria for depression within the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Daughtry & Kunkel, 1993). Using a combined quantitative and qualitative design with concept mapping, students consistently expressed somatic characteristics of depression, such as feeling sick, being tired, having difficulty concentrating, and losing appetite. Although these experiences are consistent with standard diagnostic criteria of depression, the experiences reported were not limited to a specific theoretical model or diagnostic criteria. Because of the multifaceted nature of the depressive experiences reported, it was suggested that research should broaden the definition of depression to ensure comprehensive measurement.

The college experience, if successful, should facilitate optimal development into adulthood, as students are exposed to new people and opportunities and their previous worldviews and expectations are challenged (Tanner, 2006). Traditional first-year college students, with ages in the late adolescent years or early twenties, are in the “emerging adulthood” period of development (Arnett, 2000). The emerging adulthood developmental period is a period of time during which individuals are in neither adolescence nor adulthood. In more industrialized societies, this culturally influenced emerging adulthood becomes prolonged and provides increased opportunity for identity exploration in areas such as love, world-views, and work. Individuals in the emerging adulthood period often do not identify themselves as adolescents or adults. They do not typically identify as being adults until self-sufficiency and independence with decision making are recognized (Arnett, 2000).

The need to further examine this vulnerable college population during this developmental period is crucial. The majority of published studies examining depression in college students have used a quantitative approach and have not focused specifically on the traditional freshman experience. Focusing on the experiences and outcomes that matter to the students who self-identify as experiencing depression may provide a deeper understanding of the first year in college. Quantitative research tools require participants to select from predetermined items. By requiring individuals to answer questions in only certain ways, researchers may be missing valuable and unique information that could be shared about this life experience. Arnett (2006) recommended interviewing as an effective and preferred research methodology for exploring the diversity that exists within this developmental period of emerging adulthood. Arnett (2006) argues that this time period is characterized by great variations across key areas such as identity development, school, work, and romantic relationships. Thus, it is essential to examine the freshman year and understand how those who experience depression describe this experience in their own words.

The current qualitative study was an initial phase in the development of a future grounded theory about traditional college freshmen living with depression and transitioning to university life. The purpose of grounded theory is to describe and understand social and structural processes within a specific social context. The method focuses on the evolving social experience that characterizes an event with the goal of generating a comprehensive explanation of a phenomenon (Charmaz, 2014). In the current study, open-ended questions allowed the sophomore-level college students the opportunity to freely reflect on and discuss their personal stories from freshman year. The current article presents the initial report of the major categories and subcategories following focused coding of data provided by participants. These major dimensions provide a closer look into the emotional symptoms experienced by students in their day-to-day lives.

Method

Using a grounded theory approach, the descriptive qualitative design was performed with sophomore students to understand the meaning participants gave their freshmen experiences with depression. Although the fifth edition of the DSM (American Psychiatric Association, 2013) has specific criteria for the medical diagnosis of a variety of depressive disorders, the purpose of the current study was to learn about students' perceptions of what they identified as the experience of depression. It was important to collect data from students early in their sophomore year to give students the opportunity to reflect on and fully describe the entire freshman experience. Following Institutional Review Board approval, in-depth, face-to-face interviews were conducted. Participants were recruited at a private, faith-based, Midwestern university during the fall 2015 semester.

Setting and Participants

Twelve traditional, sophomore-standing undergraduate students consented to participate, with 11 (92%) of these students being female. Participants' ages ranged from 19 to 22 years (mean = 19.92 years). In an open-ended question that did not provide categories of religious affiliation as prompts, 67% of the sample identified their religious affiliation as Christian, 25% identified as Catholic, and 8% identified no religious affiliation. The ethnic composition of the sample was 75% Caucasian, 17% Hispanic, and 8% African American. The religious and ethnic characteristics of participants mirrored those of the total student population on campus, although gender did not. The university's gender mix at the time of data collection included 50% female students. Two (16.7%) participants indicated they previously sought treatment for depression, with one seeking treatment prior to college and the other using the university's free counseling services during sophomore year.

Data Collection

To recruit students, scripted class announcements were provided in sophomore-level classes across campus early in the fall semester. These announcements described the desire to learn about students' individual experiences with depression and adjusting to the first year of college. When students responded to the primary investigator (J.M.B.), a scheduled time and private setting agreeable to each participant was determined. Prior to obtaining informed consent, students were told they would have the opportunity to discuss any aspects of their experience living with depression during the freshman year. After informed consent, participants completed the interview with the primary investigator. Interviews began with the same open-ended question: What was the experience of your freshman year in college? Few prompts were used because students freely elaborated on their experiences. When prompts were necessary, they typically occurred toward the end of the interview. The most frequent prompt was: Is there anything else you would like to share? Each interview was audio recorded, transcribed verbatim, and reviewed by the primary investigator for accuracy. In appreciation for their time, students who completed the interview received a $20 stipend.

Data Analysis

The research team analyzed interviews using constant comparative methodology (Charmaz, 2014). The process involved multiple stages of data analysis. Transcripts were analyzed line by line, with open coding by the investigators. Following each interview, the team met to analyze the collected interviews to discern emerging patterns. As interviewing continued, analysis progressed to a more interpretive form of focused coding that resulted in final categories and subcategories. This process allowed for the constant comparison of findings throughout the data analysis process and ensured an in-depth understanding of the process of living with depression as a freshman college student. Throughout data collection, memos were kept on each interview. Data collection continued until all investigators agreed saturation had occurred, with no new categories emerging to describe students' experiences.

Tactics to ensure rigor were used throughout data collection and analysis. The primary investigator verified transcriptions for accuracy (Braun & Clarke, 2006). Memoing and discussion with all investigators allowed for open analysis and interpretation of coding. As analysis progressed, the open discussion led to consensus and refinement of focused coding and development of each category. Constant comparison acknowledges that each investigator brings personal experiences to the study. This knowledge can come from literature reviewed and personal experiences (Thompson, 2011). Use of multiple investigators with unique expertise allowed for enhanced understanding of students' experiences with depression during their first year at college (Glaser & Strauss, 1967). The research team collectively represents the fields of psychology and advanced practice nursing, possessing clinical practice and research expertise with the college student population.

Results

Initial transcript reviews completed independently by the three investigators (J.M.B., T.A.K., C.H.G.) resulted in six common categorical identifiers used by each investigator during open coding. Although the exact word identifiers were not assigned by each investigator, there was 100% agreement that the same categories were used by each to code information. The initial categories included: (a) symptoms and emotions, (b) transitions and expectations during freshman year, (c) family connections and influence, (d) connections with peers/groups/socializations, (e) life story and background, and (f) suggestions for helping self and others. The team believed it was most important to initially focus on the category of symptoms and emotions, which students expressed as they lived day to day with the experience of what they identified as depression. Because students intertwined the ways in which symptoms and emotions holistically affected their daily lives, the team decided this category warranted initial focus.

Repeated analysis of transcripts by each investigator facilitated the coding process and revealed four subcategories that emerged from the preliminary review of the symptoms and emotions category. The final subcategories included: (a) expressions of stress, (b) changes in eating habits, (c) sleep issues, and (d) procrastination. For each of these recurring subcategories, an elaboration of findings with specific examples is provided. The selected quotations are representative of multiple participants for each category and subcategory.

Expressions of Stress

A recurring subcategory throughout the analysis was students' expressions of stress. Expressions related to stress were broad and included reflections of what it was like to begin college. Starting college was a clearly demarcated point in time and began a new journey for students as they transitioned into emerging adulthood. One student summarized the suddenness of the experience by stating: “You are inserted right into the middle of everything at the beginning, and it's tough. It's not, it's not an easy thing. So, for a lot of people it's overwhelming.”

Although students never directly articulated what they meant by “stress,” stressors were exacerbated by students' recognition that inconsistencies existed between what they perceived to be occurring in freshman year versus what was expected or anticipated before entering undergraduate studies. Students recalled learning about college from family members, friends, social media, and even media sources, such as movies. Students were able to recognize that some of what they experienced did not match their expectations. For example, one student remarked: “But like I only had experienced college like from movies and from like what friends would tell me. And it was definitely like not what I expected when I came here.” Not only did students describe the psychological impact of stress, they also described their physical symptoms related to stress. There was a wide range of symptoms. Students expressed anxiety, nervousness, and bouts of crying alone in their room. They even drew conclusions about their stress symptoms. For instance, one student self-described an event that she called a “nervous breakdown,” stating:

I just fell apart, and I just ended up in my room, and I just lost it—I think one time I had a nervous breakdown, and I literally just cried in the closet for 2 hours, because I had my own room at the time. And I said to my friends, “I don't think I could do this. This is going to kill me.”

Another student recalled the event as more of an emerging health crisis:

I mean, my chest would hurt sometimes. Like I ended up in the ER—well it was like this thing for students—what? Like twice because I was so stressed. Like I was having panic attacks, and like—it was just really bad. And I mean, it was terrible.

Furthermore, students expressed not feeling prepared for the socialization demands that were necessary as freshmen because of their misperceptions of what the freshman year would be like. Students made it clear that better attachment to others could help reduce the stress experienced in their new college environments. Some students acknowledged that more contact with family may be helpful, and others thought connecting with other students may be a solution.

Changes in Eating Habits

A second recurring subcategory was changes in eating habits. Students reported an awareness of eating either more or less than they used to eat. For students who reported eating more, it appears they were using their food in-take as a method of coping with what they perceived to be stress:

Like I tried working out and stuff like that. I gained some weight. But I mean, the freshman 15 or whatever they want to call it. But it should be called the stress 15 because that's why.

Students reported using food to mask uncomfortable emotions, such as sadness. One student described eating ice cream: “So, when it like first starts to happen, you're just like okay. I feel really sad right now. I should probably go eat ice cream or something.” Other changes in eating habits were a result of not maintaining regular meals. For instance, students would regularly skip meals and then end up eating too much when they did eat because they were so hungry. Not only did they eat too much at these meals, they tended to make poor food choices. One student described this yo-yo process:

I think I gained some weight, too, because I wasn't eating all day. I'd wake up so early and have to get back to the school. Wouldn't eat breakfast. Be in class during lunch. Couldn't eat. Then I would wait till I got home to eat. And then I'm eating this fattening stuff because I'm starving.

For students who reported eating less food, it appears they related their decreased appetite to other physical symptoms they perceived as depression:

I lost weight, I lost like 10 to 15 pounds because I wasn't hungry and when you sleep a lot you also—that like, I don't know, at least for me when I sleep it can sort of—I'm not hungry when I was up right after sleeping because my stomach feels all weird and so when I was sleeping a lot I was just not hungry.

Other students reported not eating because they did not have a desire or appetite to eat, which led to weight loss. One student summed up this experience by stating:

Another sign that I had was I stopped eating for a while. I actually lost 20 pounds when I went to school because I stopped eating. I literally went and had one meal a day, and I could not, I had no appetite anymore.

The majority of students reported change in their eating habits. Although some students tended to eat more to cope with their feelings during their freshman year, others ate less, causing them to lose weight. Students who reflected back on this experience frequently attributed their eating habits to be a direct result of what they were experiencing in terms of depression.

Sleep Issues

The third subcategory was sleep issues. Students reported experiencing significant sleep issues during their freshman year in college. Sleep issues represented difficulties with sleeping either too much or too little. One student reported feeling the need for an increased amount of sleep:

I felt like all I wanted to do was sleep, and it started to get to the point where like I didn't want—I was so tired that I couldn't find the energy to go to class in the morning.

Other participants, however, reported an inability to sleep, which was attributed to student demands and having too much to think about. Several students directly attributed their sleep issues to what they defined as depression. One student succinctly reported: “…but it was mostly I would just be tired all the time and like hard to get out of bed. You know, the typical depression symptoms.”

Participants reported using excessive sleep as a coping mechanism to avoid stressors in their lives. One participant stated: “I just wanted to lay in bed all day. I didn't want to get up and do anything because I knew how bad it was.” Using excessive sleep to cope with stressors proved to be detrimental because of the negative impact it had on class attendance. This was the case for one student, who reported sleeping instead of attending class:

You are so tired and exhausted that you're like oh, I'm just going to sleep for 2 more minutes, and then 10 turns into an hour, an hour turns into 5, and then you just don't get out of bed, and you don't go to class.

Students who experienced insomnia identified the desire to return to their previous normal sleep habits. One student described difficulties falling asleep: “Like I couldn't even fall asleep. Or I would just be too tired to where I couldn't fall.” Another student who was experiencing insomnia described taking over-the-counter medications to help improve sleep:

So started getting those—I don't know what they're called because I don't do it now, but it was just like maybe Tylenol® PM, to where I would take like one at bedtime and it would like help me sleep throughout the night. And like I would wake up like feeling better. But that was the only way I could like fall asleep.

Most students reported changes in sleep habits during their freshman year. These changes included sleeping too much or too little. Regardless of the type of sleep issue, participants reported significant distress in their lives due to these changes.

Procrastination

In the fourth subcategory, participants described their experience with procrastination. Students not only procrastinated, but also felt immobilized and unable to complete tasks. The experience typically resulted in students lacking motivation to manage day-to-day collegiate activities. As one student stated, “I didn't want to go to class. I really didn't care. I felt like I was in like a big pond and like if I was scuba diving, no more air. That's really how I felt.” Another student directly attributed issues with procrastination with what was defined as depression:

Getting motivated to do something that just made you sad but also it was hard for me to get motivated to write papers because I don't like writing papers. So, I would put things off until the very, very last minute.

Even if students were able to make it to class activities or do school work, they described needing to retreat to their dorm rooms and not wanting to keep going or do what should be done. It appeared procrastination led to an immobilization and inability to participate in any daily activities. One participant stated:

So I felt like, oh my gosh, can I really make it through this and I just didn't want to do anything. I would go to class and I would go back to my room and I would just like lay there...

Participants identified these changes as something they had not experienced prior to their freshman year in college. One participant stated:

I got really upset. And then I didn't want to go to class. I didn't want to see my friends. I didn't want to be around little kids, which is very, very odd for my personality. I didn't really want to do anything.

The need to procrastinate and inability to participate extended to lack of desire to engage in social activities with classmates and friends at college. One student reported:

I didn't want to go out and have fun or I didn't want to go bowling or the movies or whatever that we normally do with our little prime group we have, and I just didn't want to do any of that...

Students not only identified the feeling of being immobilized as a new experience in their lives, they also expressed frustration with themselves for not being able to be involved. One student stated:

You can do more. You can do better and you're just sitting there like crying, like stop it. Get up and do something… I was like, you can't keep doing this to yourself. You can't keep being upset. You can't keep just sitting here because really you're doing nothing but sitting here making your bed wet. It's ridiculous.

When reflecting on their freshman year, students reported not being able to complete daily activities important to academic success and overall well-being. Each student experienced this differently, but collectively, students fell along a continuum of being unable or unwilling to meet their day-to-day needs.

Discussion

College students who chose to discuss their unique experiences with depression during freshman year reported physical and emotional symptoms that are typically associated with symptomology of depression. These symptoms and emotions, which were recurring subcategories throughout the interview data, included (a) expressions of stress, (b) changes in eating habits, (c) sleep issues, and (d) procrastination. Although extensive literature is available on depression in college students, little research has examined the freshman year in a qualitative, holistic manner, using unprompted descriptions. Students who participated in the study chose to freely discuss the physical and emotional symptoms they associated with depression during their freshman year. Their perceived experiences impacted their academic year and social connections, and likely reduced their opportunities to actively explore the major life events that are part of the emerging adulthood developmental period described by Arnett (2000).

Findings from the current study were similar to findings of other research, in which freshman students experienced depressive symptomology (Brandy et al., 2015; Bruffaerts et al., 2017) or psychological distress and physical symptoms (Pritchard et al., 2007). In addition, when examining data in the literature on introductory college courses, which often contain freshman students, findings were also similar to the current study. In Dixon and Robinson Kurpius (2008), feelings of stress were predictive of depression in students in introductory courses. In the current study, students specifically described changes in sleep habits, including increased and decreased sleeping habits and insomnia. Gress-Smith et al. (2015) found that approximately one third of students in an introductory course reported significant levels of depression and insomnia. Students in the current study also reported changes in eating habits and procrastination or the inability to keep up with daily expectations; however, with little data on freshman students in the literature, it is not clear if these symptoms are universal.

Although responses suggested that students desired positive social interactions to help them cope with stressors associated with the freshman year, the subcategories identified in the coding process (e.g., expressions of stress, increased need for sleep, changes in eating habits, procrastination) suggested that there may have been barriers to their success at making social connections at college, finding appropriate supports, and becoming more self-sufficient as an individual. The importance of social support as a protective factor against the development of depressive symptoms in freshman college students has been shown to be significant (Brandy et al., 2015; Friedlander, Reid, Shupak, & Cribbie, 2007). For students unable to overcome common barriers to making social connections, successful transition to college life may be difficult.

Only two (16.7%) participants in the current study reported seeking professional treatment for symptoms they identified as depression, and no participants reported seeking assistance during their freshman year. One student's treatment was initiated prior to college, and the other student did not seek professional assistance until the beginning of sophomore year, despite knowledge of the availability of counseling services on campus during freshman year. These results are similar to results from an ACHA (2015) nationwide survey. This lack of seeking professional assistance is concerning, because unrecognized and untreated depressive symptoms can lead to negative life events in the lives of college students and have a negative impact on their transition to adulthood. Further research is needed to explore reasons college students may not seek assistance for negative emotional symptoms despite availability of free counseling services on their college campuses.

The initial results of this qualitative study using grounded theory methodology prompt the questions: Could underlying depressive symptomology be undermining college success at the onset of the college experience by reducing positive social interactions and connections? If so, is depressive symptomology being intensified with newly introduced stressors of the college experience? Or are depressive symptoms merely an adjustment to new stressors related to being a college freshman?

Limitations

The findings are an initial analysis of data about sophomore students and their experiences with depression and transitioning to the freshman year of college. These findings may have some potential limitations based on the setting and characteristics of the participants. To begin with, recruitment of participants was completed via class announcements across campus, and those who chose to participate may not be reflective of all students who experience symptoms of depression as freshmen on campus. Although participants' characteristics were similar to those of the university, the sample included proportionally more female students. Research findings demonstrated that female students reported greater depression and academic stress than male students, which may account for the higher numbers of female participants (Dixon & Robinson Kurpius, 2008). Second, students volunteered to participate in the study, and no measures were taken to confirm an actual diagnosis of depression during their freshman year. Third, the sample size was small; however, all members of the research team agreed that saturation in categories emerged. Finally, participants were students from the same university, a private, faith-based school located in the Midwestern United States, and may not be applied beyond the context and participants in this study.

Implications

Initial analysis of data presented in the current article has provided a closer look into depressive symptoms and emotions experienced by students. The data provide a unique perspective from the voices of students who self-identified as experiencing depression during their freshman year. Although the sophomore-standing students were recalling their experiences as freshmen, they have articulated a holistic perspective of how they remember the experience and what it meant to them.

This pilot study has provided a starting point for a more comprehensive study that will enable the team to develop a grounded theory based on the experience of depression during freshman year. The research team will continue to explore other categories to gain greater understanding of the experience of living with depression as a freshman college student. These other categories include: transitions and expectations during freshman year, family connections and influence, connections with peers/groups/socializations, life story and background, and suggestions for helping self and others.

Conclusion

With a greater understanding of depression during the freshman year of college, mental health professionals will have additional evidence to guide their professional practices with students during this vulnerable period of their development. Furthermore, findings from the current study may be useful in the construction of standardized instruments designed to identify students at risk for depression. Although there are limitations, results of the current study may provide insight into prevention and treatment strategies to help college students move more successfully through the freshman experience, thus allowing a better evolution through the stage of emerging adulthood.

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Authors

Dr. Brandy is Associate Professor, Nursing, Dr. Kessler is Professor and Kreft Endowed Chair, Advancement of Nursing Science, College of Nursing and Health Professions, and Dr. Grabarek is Associate Dean, Graduate School and Continuing Education, and Associate Professor, Education, Valparaiso University, Valparaiso, Indiana.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Funding for this study was provided by Wheat Ridge Foundation.

Address correspondence to Julie M. Brandy, PhD, RN, FNP-BC, CNE, Associate Professor, Nursing, Valparaiso University, College of Nursing and Health Professions, 836 LaPorte Avenue, Valparaiso, IN 46383; e-mail: Julie.brandy@valpo.edu.

Received: December 13, 2017
Accepted: February 22, 2018
Posted Online: April 19, 2018

10.3928/02793695-20180329-02

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