Bar Code Medication Administration - Research Paper Example

Bar Medication Administration Bar Medication Administration Introduction This paper discusses the implementation of a Bar Code Medication Administration (BCMA) in a hospital setup as a new project to improve service delivery. The BCMA is a management system that uses barcodes to limit or prevent occurrence of medication errors in hospitals and improve the safety and quality of administering healthcare to patients (Cohen, 2007). The system was conceived out of the need to improve administration of medication among patients in a hospital. Medication administration is probably one of the most important goals of the healthcare system because it is such a life changing process. While the process of administering medication to patients involves a wide range of disciplines and individuals, the bedside nurse is the one who bears the greatest responsibility in the whole process (Gooder, 2011). The nurse remains the focal point in administration of medication because she is the one who makes final contact with the patients in most cases. The main objective of administering medication to patients is to provide prescribed drugs and medication in an effective, efficient and safe manner that result in the best outcomes for the patient. Several barriers, however, prevent nurses from administering medications safely and efficiently. Among such barriers, include inappropriate judgments from nurses due to inattentiveness to details and errors resulting from misinterpretation or wrong translation of prescriptions from doctors. These errors are likely to results in incorrect administration of medication, which will have very devastating results for both the healthcare providers and the patients (Cohen, 2007). Wrong medication administration can ultimately lead to death of the patients and put the hospital or healthcare facility under pressure for being negligent. Research indicates that most of the adverse outcomes in healthcare for both patients and hospitals are due to errors in medication of errors. The Institute of Medicine estimates that hospitalized patients are at risk of suffering from at least one medication administration error in a day. Errors resulting from wrong administration of medication are also costly for healthcare facilities. According to the Institute of medicine, one error in administration of medicine can cost a hospital over 4500 dollars and up to 1.5 million annually (Goundrey-Smith, 2013). Despite being measures in place such as the institution of Five Rights of Medication Administration and various policies, there is still room for human errors that can be very detrimental in administration of medication (Gooder, 2011). However, technology always seems to have an answer for most of the problems that human beings experience. Development of a Bar Code Medication Administration (BCMA) system is a major revolution that aims at improving administration of medication through minimizing human errors. The system focuses on improving patient safety and decreasing errors in administration of medication (Cohen, 2007). The BCMA system is a change that all healthcare facilities need to adopt in order to improve administration of medication and prevent several adverse outcomes and costs that are associated with poor administration of medication. The main purpose of this project is to improve accuracy of medication procedures, prevent errors, and generate patient medication records online for administrative purposes. The system will reduce the number of errors resulting from administration of medication and improve patient safety by automating the medication process and verifying medication administration processors. This will help nurses and caregivers to make appropriate decisions when administering medication to patients. Goals of the BCMA system include minimizing costs associated with errors in medication administration, increasing accuracy of medication administration processes and building trust among patients and hospitals. Implementing this project will have a huge impact on healthcare institutions, patients, their families and the wider community. Hospitals and other healthcare facilities, for instance will reduce avoid the unnecessary costs that come from errors in medication administration. The hospitals will also build a reputation of being effective in their service delivery thereby building a good rapport with their clients. The system will also make work easier for caregivers in hospitals by limiting chances of human errors and assisting in effective decision-making (Goundrey-Smith, 2013). Patients, on the other hand, will benefit from better service delivery and improved outcomes from their medication process (Gooder, 2011). The system will help develop trust among patients and provide them with hope of recovery due to efficient administration of medication. The BCMA system will also have a good impact on the relationship between hospitals and the wider community. The community will strengthen the bond between hospitals and other community members because there will be minimal issues of abrasion such as poor administration of medication to patients. The wider community will have more trust in the hospitals. The BCMA system is very consistent with the role that contemporary nurses play in administration of medication. Although the system does not replace the role of nurses and administrators in hospitals, it complements their role by improving service delivery. The role of the nurse entails checking the state of the patients from time to time, providing necessary drugs, following doctors’ prescriptions, making appropriate judgments based on the state of patients, and recommending further actions when necessary (Gooder, 2011). The BCMA system is consistent with this role of the nurse because it creates more room for the nurse to exercise her role albeit with greater accuracy and efficiency. The nurse can still play her role in administration of medication while the system will only be in place to facilitate the nurse in making appropriate decisions, verifying the nurses’ actions and helping in record maintenance (Cohen, 2007). The system helps the nurse in determining many issues regarding the patient and the medication in order to avoid cases of errors occurring. The main objective of the nurse in administration of medication is to provide efficient services that will be effective in restoring the health of patients. The system is also consistent with this objective because it facilitates nurses to work in a secure environment that is free of human errors. The BCMA consists of both hardware and software that are designed to improve service delivery in healthcare. The system consists of a barcode reader, a computer, appropriate software application and wireless network connection. The system works in a manner that each patient admitted in a hospital will be assigned a barcode. Each time a nurse administers drugs or treatment to a patient, the nurse will scan the barcode placed on a patient’s arm. This will help ascertain that the patient is the right person for that medication. The nurse will then scan the barcodes on the drugs before giving the patient. The application software will read the barcode to determine and verify whether the drugs are the right dose for the patient, and help the nurse identify the right time for administering those drugs. One of the main purposes of the BCMA system was to help nurses and caregivers in healthcare facilities in administering medications for patients. The system, however, is not meant to replace the nurse’s professional judgment and expertise. BCMA is not a completely new technology in healthcare. The system was first implemented at the Colmery-O’Neil Veteran Medical Center in Kansas in 1995. The idea of creating the system was conceived by a nurse who derived her inspiration from a barcode system she saw at a car rental service. Due to its success at the Colmery-O’Neil Veteran Medical Center, the BCMA system continued to gain support from different sectors in the healthcare industry. Between 1999 and 2001, usage of the BCMA system grew to over 160 healthcare facilities (Goundrey-Smith, 2013). The Department of Veteran Affairs was very vocal in its support for the system leading to the systems popularity in healthcare facilities. The system was mainly hailed for its role in reduction of medication errors in administration of medication to patients in hospitals and other healthcare facilities. Research Review Bar Code Medication Administration (BCMA) has taken the nursing sector by storm since the technology first came to the scene. BCMA has attracted a lot of attention and scrutiny with many scholars, nurses and researchers in the healthcare sector interested in finding out more about this latest technology. As a result, there have been several studies conducted to determine the suitability, effect and significance of BCMA in contemporary nursing. This literature review explores different studies about BCMA and medication errors. This research review resulted in many viewpoints about BCMA including different perspectives of multidisciplinary teams, barriers to BCMA, Administrative issues, and concerns about implementation of the technology and varying levels of satisfaction among nurses. These are the main themes that were most common among the articles and books reviewed for this literature study (Gooder, 2011). One important point discussed I most of the literature is the view that the system needs to be made better and safer with the need of overcoming the emerging barriers also emphasized. A significant amount of research reviewed focused on implementation of the BCMA technology in hospitals to help nurses. Like any other new system, or change initiative, implementation always comes along with many challenges and barriers that can threaten success of the project if not appropriately addressed. In most of the studies, however, most of the challenges and barriers of initial implementation of the system were addressed accordingly and the system took off successfully. Implementation of the BCMA system requires an interdisciplinary approach bringing together information technology professionals, nurses, patients, physicians, and administrators of healthcare facilities. Leaving out one or more of these key individuals and stakeholders is likely to jeopardize the implementation of the system in the long-run. Implementation of the system also has to be approached retrospectively where all the stakeholders collaborate effectively to design the goals and objectives of the project. It is also important to put a team in place to manage the transition process from manual management of patients to the automated system through the BCMA technology. According to Ross (2008), this implementation team is referred to as the collaborative design team. Different hospitals also have different needs that have to be taken into account when implementing the BCMA system. These needs have to be aligned to the objectives of BCMA in order to chive the desired goals. Other members of staff also have to be involved in the system implementation through training and providing feedback that can help improve the system. Other researchers focused on the emerging issues in implementation of the BCMA technology and the challenges that the system faces. One major issues in implementation of BCMA is that the system slows down disrupts operations in the hospitals and slows down the process of administering medication to patients (Cohen, 2007). Technology is supposed to improve the process of medication administration, but not the other way round. With this technology, nurses have to verify every step they take in the process of administering medication to patients. This leads to unnecessary delays in decision making, albeit the final decisions come with improved accuracy (Goundrey-Smith, 2013). Some nurses also felt like the system took over the role of administering medication from nurses and gave such a vital role to machines. There is likely to be a conflict between man and machine in the process of medical administration. While humans are flexible and can adjust themselves depending on the situation at hand, systems are more rigid and static and are unlikely to behave differently. The system is also likely to shift the attention from nurses to technology. This is because as the system becomes more reliable, hospital administrators will become more reliant on the system at the expense of nurse. In order to address these challenges, hospital administrators have to rewrite some of their policies and put in place strategies and measures to ensure a seamless transition process. According to Weckman and Janzen (2009), it is very critical to involve nurses in any change project in hospitals and patient care settings. Nurses have a crucial role to play in implementing new technology such as the Bar Code Medication Administration (BCMA) system. The authors examine a critical role that nurses played in designing, planning, implementing, and evaluating BCMA in a patient care facility through interdisciplinary teams. They show the significance of involving nurses in all the levels and phases of introducing the new technology. They also point out several problems that can arise if the nurses do not play any part in introducing the system. One such challenge is resistance to change, which may lead the system to falter. One researcher, Gooder (2011), for instance, examines the perceived impact of BCMA on the ability of nurses to provide medication, their levels of satisfaction, and their perception of medication errors. The researcher used a questionnaire founded on Rogers’ diffusion of innovation theory to establish validity of the content of his study. His study indicates that there is a decreased level of general satisfaction among nurses with the implementation process of BCMA technology. The researcher also found out that implementation of BCMA has a negative impact on attitudes of nurses towards the process of administering medication, which makes their work more difficult. The author points out that effective implementation of BCMA requires collaboration among different stakeholders in order to find out the impact the system will have on how the nurses and other employees work. Harrington, Clyne, Fuchs, Hardison, and Johnson (2013) bring in a different perspective in their research. In their article published in the journal of Nursing Administration, they endeavor to assess whether the BCMA technology is currently being implemented according to emerging evidence on how the system should be used. The researchers used an evidence-based checklist when assessing how the system is used in acute care settings in various healthcare facilities to determine if the usage of the system complies with current evidence. The researchers found out that there was about 72% compliance among the hospitals they evaluated. After implementing various quality improvement strategies, the level of compliance rose to 81%. The evidence-based checklist the researchers used came in handy in identifying gaps in how the system was being used, thereby making recommendations for improving implementation of the system and aligning the system to evidence based practice in nursing. Rack, Dudjak, and Wolf (2011) examine the impact of the BCMA system on nurse workarounds in hospitals. The authors used nurse focus groups and various surveys to determine the potential cause and the frequency with which nurses conducted workarounds. The researchers found out that more than half of the nurses they assessed administered medications to patients without appropriately scanning patients, especially in the last shift of work (Goundrey-Smith, 2013). This study is very significant to the healthcare sector because it provides useful insights for implementing bar code medication administration technology in a manner that minimizes the development of many workarounds in nursing practice. Key Stakeholders and Communication Points Implementing BCMA, like any other change project, must bring all stakeholders on board in order to be successful. BCMA technology is a multidisciplinary change initiative that brings together professionals with different objectives to achieve a common goal. BCMA technology requires expertise and input from nurses, administrators, pharmacists, and IT professionals. These are the main stakeholders in initiating, planning, designing, implementing and evaluating bar code medication administration system. Each of these groups of individuals plays a critical role in the success of the system and cannot be overlooked. The nurses, for instance, are the main users of the system. They play a crucial role in reducing errors in administration of medication. The nurses handle patients on a daily basis and have the greatest responsibility in the process of administering medication. The nurses will form a link between the system and the patients and will use the system to improve the outcome of their work. Hospital administrators are charged of major decision making in patient care facilities. They play an important role in terms of approving major changes in any of the process in their facilities and have the responsibility to drive their organizations toward realizing their objectives. They also ensure that the facilities have the best relationships with other organizations and the wider community. The administrators, therefore, will play a significant role in approving a decision to adopt and implement BCMA systems in their facilities (McCarthy, Schafermeyer, & Plake, 2012). They are essentially project managers who oversee change initiatives to their successful completion. Pharmacists also play a vital role in hospitals and in the process of administering drugs. They have the role of promoting effective and safe medication process in healthcare facilities. They, therefore, ensure that patients receive the right dosage at the right time, and in the best manner (Harrington, Clyne, Fuchs, Hardison, and Johnson, 2013). They work with other stakeholders such as nurses in improving outcomes of treatment for patients by minimizing side effects for their ailments. Part of the BCMA system is to promote effective and efficient medication process through ensuring patients receive the right dosages at the right times. The pharmacists, therefore, will use the system to verify doses of patients and give drugs appropriate barcodes that indentify specific drugs given to particular patients in order to avoid confusion (Harrington, Clyne, Fuchs, Hardison, and Johnson, 2013). On the other hand, IT professionals play a significant role in managing information technology systems in healthcare settings. They ensure that all systems function well and make any repairs or troubleshooting to bring systems back to normalcy. The IT professionals also have the role of educating and training other employees on how to use new systems and technologies (Weckman, and Janzen, 2009). As such, the IT professionals will have a significant role to play in implementing the BCMA system. These groups of key stakeholders have to be persuaded to adopt the new technology that will come with the implementation of the BCMA system. Persuasive arguments for each groups of stakeholders have to take in to account the needs of each stakeholders in relation to the benefits that the system will bring to their roles. Firstly, it is important to convince the hospital administrators to adopt the new BCMA technology. This is because once administrators approve the system, it will be easier to reach out to other uses and stakeholders in the system. In order to convince and persuade the administrators to endorse the new BCMA project, it is important to explain to them how the system will improve decision making and reduction of errors in administration of medication (Cima, Clarke, & Joint Commission Resources, 2012). The system will help the hospital achieve its goal of saving lives and improving patient outcomes from treatment. The system will also help the hospital to save on costs that are associated with medication errors. Implementing BCMA will also help the hospital to have improved relationships with users of their medical services, business partners such as suppliers, local authorities, and the wider community (Richard; Brown; Scanlon, and Karsh, 2011). The hospital that implements the system is also likely to be the center of reference and a good example for other hospitals in terms of minimizing medication errors. In this regard, if the administrators endorse the system, they will be better placed to achieve the goals and objective of their organization. In persuading IT professionals, it is important to point out that the system is cost effective, efficient, and manageable and complements other systems in place. IT professionals are mainly interested in the functionality of the system and whether it can help the organization meet its objectives. The BCMA technology is relatively simple and very effective. All that is requires is a computer, internet, and barcode reader for the system to work (Kelly, Vottero, & Christie-McAuliffe, 2014). The system is also not technical and does not require a lot of hours training employees. The system can also be seamlessly adapted in to the organization without causing much disruption in the current structures (McCarthy, Schafermeyer, & Plake, 2012) The IT professionals will find the BCMA system to be one of the best technologies in the hospital because of its direct impact on improving patient outcomes and assisting nurses to administer medication to patients. Pharmacists play a direct role in some of the medication errors which are mostly attributed to human errors. Some of the difficulties in making the right judgments in certain situations may have profound impact on patient outcomes. This is because human beings make decisions based on emotions and may be distracted from the core issues involved. A new system will help increased the accuracy of decision making for pharmacists. The system will help pharmacists verify the right dosages for the right patients in order to avoid unnecessary confusions (Kelly, Vottero, & Christie-McAuliffe, 2014). In convincing pharmacists to accept and endorse BCMA technology, it is important to point out the impact that the system will have on their work. The pharmacists will be relieved of the challenge of recalling dosages for each patient since the system will come in handy for storing and retrieving such information when needed (Gooder, 2011). The pharmacists will also make minimal mistakes in their work once the system is implemented since the BCMA system will make their work easier. It is also important to point out to them that the new system will not replace them in their roles, but will only complement their efforts and ensure they play their role efficiently. Finally, the nurses comprise of the last group of stakeholders that have to be convinced to adopt the system. The nurses have a very special role to play in implementing the system because they will be the ones who will interact with the system ion a regular basis. This is because of their role in managing patients in hospitals. Most studies indicate that the nurses have a negative attitude towards the system because they feel that it will replace them from theory duties. It is therefore important to take this into consideration when convincing nurses to adopt the system. It is very important to put all their fears to rest by stressing that the system will not replace them but will only complement their role. The system will make work much easier for nurses in terms of reducing errors and facilitating accurate decision making in administration of medication. Implementing the system, however, will not be an easy task. This is because of the various issues that are likely to emerge through the implementation process that may derail the system from achieving its objectives. Among some of the hitches that are likely to undermine the implementation process, include resistance to change, overreliance on the technology, and mismanagement. Resistance to the change process may come from any of the stakeholders (Roussel, Swansburg, & Swansburg, 2006). Resistance may result from disagreements, misunderstandings, and loss of trust among key stakeholders. Resistance to change is a common occurrence to most change processes and has to be properly addressed in order to steer the project to successful completion. The other likely challenge to the implementation process is overreliance to the technology. This comes as a result of the hospital disregarding the value of human beings in the process of administering medications. While systems may be accurate, they are very rigid and inflexible (Harrington, Clyne, Fuchs, Hardison, and Johnson, 2013). They are not responsive to changes in circumstances and do not have human capabilities, which are vital in treatment of patients such as empathy and sympathy. The other challenge is mismanagement. In order to the system to be successful, it is necessary to have in place great leadership to see through the implementation process. It is important to have an implementation team to guide manage the implementation process (McCarthy, Schafermeyer, & Plake, 2012). Mismanagement leads to improper allocation of resources and failure to prioritize issues relating to implementation of the system. A useful strategy for implementing the system effectively is applying Kurt Lewin’s change management theory. This is a classical three-step change framework for initiating change in healthcare environments. The three steps are unfreezing, change and freezing. Unfreezing, which is the first step, entails determining the main reasons for change and the necessity of change given the current circumstances. Change involves initiating the change process and transitioning to the next desired state. The final stage, freezing or refreezing is about finding stability after the change process. Using this model of change, the administrators of a healthcare facility can assess the current situation and determine the need for initiating change (McCarthy, Schafermeyer, & Plake, 2012). Part of the reason to bring in this change is to minimize medication errors, improve decision making for nurses, and reduce costs associated with medication errors. The second part involves initiating the change process to address the challenges identified in the first step. Finally, the last step involves finding stability and managing the post change environment to help the organization work efficiently within the new environment. Operationalization of Project Operationalization of BCMA is a long process that must be approached with a lot of keenness. Like any other change project, BCMA requires a lot of planning and strategizing. The first step in implementing BCMA is establishing the need and urgency of implementing the project. The hospital implementing the project must examine its processes to determine whether the project will succeed. This step takes about four weeks, depending on the size of the hospital or health facility in question. Ignoring this step is likely to leads to complacency and creates a false urgency for implementing the project (International Congress in Nursing Informatics, Saranto, & IOS Press, 2009). The next step is putting together an implementation team that will be charged with implementing and managing the change. The team has to include representatives from all the stakeholders in order to have views of all interested parties represented. The team should also have enough credibility, leadership, expertise and positional power. The team will be charged with the responsibility of creating vision and objectives of the change process. The next step is communicating the vision and objectives of the change project to all the stakeholders in order to have them accept the project. Communication of the vision involves constant and continuous sharing of information and views about the impending project through emails, social media, conferences, workshops and other organized platforms where the implementation team illustrates the significance of the change (Goundrey-Smith, 2013). This helps the other people in the organization to understand the project in detail and be ready to accept it. This step is also important because it helps to overcome resistance to change, which can have adverse effects on the project. This step takes about four to six weeks (Liang, 2010). This process also entails communicating roles of each stakeholder in the project. In the BCMA project, the roles of administrators, pharmacists, nurses, and IT professionals have to be well understood. After preparing for the change effectively through the three steps above, the organization is now ready to begin the implementation process. This begins with aligning each department that is related with the BCMA project to the objectives of the change project (Sutherland, 2013). The first step to address in implementing the BCMA project is aligning the pharmacy department to the project. BCMA requires all drugs in the pharmacy department to be configured correctly and packaged appropriately. All the drugs have to be given barcodes and entered in to the system (Liang, 2010). This process may take longer depending on the size of the pharmacy department, but it can last for between three to four weeks. The next step is to restructure the IT department by installing the appropriate hardware and software applications that will help run the BCMA project. This entails putting in place a wireless internet network, barcode scanners, and computers (Harrington, Clyne, Fuchs, Hardison, and Johnson, 2013). All these equipment have to function properly. In some cases bar code arm band printers may be needed to complement the available hardware and software. There is also need to establish a workstation that will be responsible for managing the BCMA system. The next step is realigning the nursing department to the needs of the system. This step entails restructuring the admissions section to ensure that each patient admitted in the hospital is duly registered and given a readable barcode (Liang, 2010). Barcodes must be reprinted when they become unreadable. This process ensure that each patient is identified by the system, thereby making the process of administering his or her medication easier. Workstations also have to be installed closer to the wards where patients are for easier access (Kelly, Vottero, & Christie-McAuliffe, 2014). Communication lines have to be constantly open throughout the day in order to report emerging issues. This step takes about four weeks. The final step is the maintenance. BCMA is not an end in itself, but rather a continuous process that aims at improving provision of medical services in hospitals and administration of medication (Potts, & Mandleco, 2012). This involves continuously registering new patients, repairing equipment and installing new systems, reprinting barcodes and recording new drugs in the system. The steps involved in Operationalization of the BCMA project can be summarized as below; 1. Establishing the need and urgency of implementing the project- 4 weeks 2. Putting together an implementation team- 3 weeks 3. Communicating the vision and objectives of the change project- 4-6 weeks 4. The implementation process- (10-11 weeks) Aligning the pharmacy department to the project- 3-4 weeks Restructuring the IT department- 3 weeks Realigning the nursing department to the needs of the system- 4 weeks Evaluation Parameters Evaluation of any change project is a very important step because it assesses whether the change initiative met its initial objectives. There are several parameters that can be used to assess the effectiveness of the BCMA system once it has been installed. There are several strategies of evaluating the BCMA system. These include observation, user experience evaluation, surveying through questionnaires and using the 7-point Likert scale. Observation entails looking at how different users use the system and determining whether they achieve their intended objectives. Evaluation of user experience involves determining whether the users enjoy working with the system, or whether they dislike the system. Online questionnaire surveys and the liker scale can be used to assess user experience. The three main parameters for evaluating the BCMA system are validity of the barcode scanning process, the validity of administration of medication process, evaluation of the technology involved, and evaluation of user experience. These factors are important parameters for evaluating the system because they help administrators of the system to gauge whether the BCMA system meets its intended objectives and whether it improves the hospital in any way. Evaluating the validity of the medical administration process, for instance, entails determining whether the BCMA system improves the process of administering medication to patients (Liang, 2010). This is in accordance with the objective of eradicating errors in administration of medication. Evaluation of scanning process determines whether the barcode readers are functional; and whether they improve the process of identifying patients and verifying dosages for each patient. Evaluating technology looks at whether the technology involved in BCMA is safe for patients, nurses and other users (Rack, Dudjak, and Wolf, 2011). BCMA is supposed to be a user-friendly system that promotes a healthy and safe environment for administration of medication. Evaluation of user experience involves assessing the attitudes of users towards the system. This determines whether the users, such as nurses like the system and whether they are comfortable working with the BCMA technology. References Cima, L., Clarke, S., & Joint Commission Resources, Inc. (2012). The nurses role in medication safety. Oakbrook Terrace, Ill: Joint Commission Resources. Cohen, M. R. (2007). Medication errors. Washington, D.C: American Pharmaceutical Association. Gooder, V. (2011). Nurses’ Perceptions of a (BCMA) Bar-coded Medication Administration System: A Case-Control Study. Online Journal of Nursing Informatics, 15 (2), Available at http://ojni.org/issues/?p=703 Goundrey-Smith, S. (2013). Information technology in pharmacy: An integrated approach. London: Springer. Harrington, L; Clyne, K; Fuchs, M. A.; Hardison, V., and Johnson, C. (2013). Evaluation of the use of bar-code medication administration in nursing practice using an evidence-based checklist. Journal of Nursing Administration, 43(11):611-7. Kelly, P., In Vottero, B., & In Christie-McAuliffe, C. (2014). Introduction to quality and safety education for nurses: Core competencies. McCarthy, R. L., Schafermeyer, K. W., & Plake, K. S. (2012). Introduction to health care delivery: A primer for pharmacists. International Congress in Nursing Informatics, Saranto, K., & IOS Press. (2009). Connecting health and humans: Proceedings of NI2009. Amsterdam: IOS Press. Liang, L. L. (2010). 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Online, Available at http://cjni.net/journal/?p=2888 Weckman, H., Janzen, S., (2009) "The Critical Nature of Early Nursing Involvement for Introducing New Technologies" OJIN: The Online Journal of Issues in Nursing, 14(2), 37-56. Read More