Suicide is the taking of own life which is a “tragic reaction to stressful life situations (Suicide and suicidal thoughts, 2015).” The national institute of health reported ages 10-24 year olds in 2014 was the second leading cause of death with a total count of 5,504 deaths in the US (Advancing research to prevent youth,n.d.).  Erickson’s stages of development for the adolescent shows the teen must successfully concur the two stages of development – identity vs. identity confusion and intimacy vs isolation (Miller, 2017).  Teens who are struggling with the first and second stage will become socially isolated (Miller,2017). Erikson’s theory predicts “when adolescents are unable to successfully answer the questions of identity during this stage of development, they may experience feelings of inadequacy and despair, which can eventually lead to depression (Miller,2017).  Depression left untreated can lead to suicide. 

             Health professionals can utilize primary, secondary, and tertiary methods to help with health prevention of suicide.  “ Primary suicide prevention aims to reduce the number of new cases of suicide in the general population. Secondary prevention aims to decrease the likelihood of a suicide attempt in high-risk patients and Tertiary suicide prevention occurs in response to completed suicides and attempts to diminish suicide contagion (Ganz, n.d.).”

                In general, if a true emergency is occurring 9-1-1 should always be the first line to call for help.  When teens are struggling through thoughts of despair and potential suicide the communities do have resources to reach out to.  As followed are some of the resources: Transitional Age youth support- Mental health services: (360)918-7860; Crisis Line: (360)586-2800; National Suicide Prevention Lifeline: (800)273-Talk (community youth services, n.d.).

                As the nurse it is our duty to obtain a precise assessment of the teen through thorough questions and observations.  The nurse should be mindful of some risk factors which place this age group at higher risk are as followed: a previous suicide attempt, mental disorders- schizophrenia/social anxiety, substance abuse, abused or mistreated, history found in family, hopelessness, lack of social support, access to means or methods for suicide (Preventing Teen Suicide, n.d.).  A main nursing intervention in assisting a suspected depressed teen is to show active listening and presence.

 

Advancing Research to Prevent Youth Suicide. (n.d.). Retrieved October 17, 2017, from https://prevention.nih.gov/programs-events/pathways-to-prevention/workshops/suicide-prevention

 

Ganz, D., Braquehais, M. D., & Sher, L. (n.d.). Secondary Prevention of Suicide. Retrieved October 17, 2017, from http://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1000271

 

(n.d.). Retrieved October 17, 2017, from http://www.communityyouthservices.org/p_suicide_prevention.shtml       

 

Miller, R. (2017, June 13). Erik Erikson’s Theory About Adolescent Depression. Retrieved October 17, 2017, from https://www.livestrong.com/article/560899-erik-eriksons-theory-about-adolescent-depression  

 

  Preventing Teen Suicide. (n.d.). Retrieved October 17, 2017, from https://teens.webmd.com/preventing-teen-suicide#1  

 

Suicide and suicidal thoughts: Take action to prevent a tragedy. (2015, August 28). Retrieved October 17, 2017, from http://www.mayoclinic.org/diseases-conditions/suicide/basics/definition/con-20033954

health 3 quest 1

 

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Respond using one or more of the following approaches:

Ask a probing question, substantiated with additional background information, and evidence.

Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.

Statistical Methods in Qualitative Research 

  

Statistical Method

What is measured by this method

Circumstances for Use

Examples of use in Research Studies

 

Qualitative Content Analysis

Analyzes narrative data, and in-depth interviews. Can evaluate large volumes of data with   intent to identify recurring themes and patterns. Attempts to break down   elements of data into clusters. May be concurrent or sequential (Polit &Beck,   2017).

Good method for evaluating personal histories, perspectives,   experiences. Best method for studying personal, sensitive situations (Sauro,   2015).

Examples of this methodology include evaluation of the experience of a   rape victim, what it feels like to have an abortion, how it feels to have   lived through a disaster.

 

Ethnographic analysis

Evaluates cultural phenomena, patterns, perspectives. Requires   “participant observer” technique. No preconceived hypothesis. May take months or years to complete. Maps and flowcharts are tools to help   illustrate findings (Polit & Beck, 2017).

Method to “acquire a deep understanding of the culture being studied”   (Polit & Beck, 2017 p. 538).

An example of ethnographic analysis could include a research study   with ethnographers integrating with Native Americans living on a reservation   while observing everyday life seeking to extrapolate overlying cultural   issues.

 

Phenomenologic Analysis

Attempts to understand the   essence of experiencing a particular phenomenon by observation, interviews,   and outside research. Descriptive analysis 

Method for understanding individual perspectives of experiencing a   certain phenomenon. Seeks to extrapolate commonalities and themes among   subjects (Sauro, 2015). 

Conducting interviews with persons who have experienced   hallucinations, with the intent to understand their perspective and   experience of the phenomenon, is an example of this method of research.

 

Grounded Theory Analysis

Aim is to provide theories and explanations for phenomena based on   previously coded information Uses interviews and previous accepted research. Unlike Qualitative content analysis, which   seeks to break down information, Grounded theory strives to put information   back together (Polit & Beck, 2017).

Method for development of theories, Could be used meta-analyses or   systematic reviews.

An example of a grounded theory analysis is” Beck’s (2002) model of   mothering twins” as cited in Polit & Beck (2017).

 

Focus Group Analysis 

Analyzes group data in relation to a specific topic. Group interviews, recordings, and field   notes .are instruments for conducting this type of research.

May be used for evaluation of a potential survey tool, consensus on a   new product. Researchers seek to   extrapolate recurring themes.

An example of a focus group analysis might be to evaluate perceptions   of a new product being marketed to test for general consensus of its   desirability. 

Quasi-statistics: a tabulation of the frequency with which certain themes or insights are supported by the data

Qualitative content analysis: analysis of the content of narrative data to identify prominent themes and patterns among the themes

Domain analysis: 1st of 4 levels of data analysis, domains are units of cultural knowledge, are broad categories that encompass smaller ones. Ethnographers identify rational patterns among terms in the domains are used by members of the culture. Ethnographer focuses on the cultural meaning of terms and symbols used in a culture

Taxonomic analysis: second level of data analysis, ethnographers decides how many domains the analysis will encompass. Taxonomy is then developed to illustrate the internal organization of a domain and the relationship among the subcategories of the domain

Taxonomy: a system of classifying and organizing terms

Componential analysis: relationships among terms in the domains are examined; ethnographer analyzes data for similarities and differences among cultural terms in a domain.

Theme analysis: cultural themes are uncovered; domains are connected in cultural themes, which help to provide a holistic view of the culture being studied. The discovery of cultural meaning is the outcome.

Holistic approach: researchers view the text as a whole and try to capture is meanings 

Selective approach: researchers highlight or pull out statements or phrases that seem essential to the experience under study 

Detailed approach: researchers analyze every sentence 

Hermeneutic circle: signifies a methodological process in which to reach understanding, there is continual movement between the parts and the whole of the text being analyzed 

Exemplars: illuminate aspects of a paradigm case or theme

Substantive codes: substance of the topic under study is conceptualized through substantive codes. Substantive codes are either open or selective

Open coding: used in the first stage of the constant comparative analysis, 

captures what is going on in the data. May be actual words stated by participant. In open coding, 

data are broken down into incidents and their similarities and differences are examined. Raw  

data interpreted 

Three Levels of Open Coding: Levels I, II, III

Level I codes: in vivo codes, derived directly from the language of the 

substantive area and have vivid imagery 

Level II codes: Researchers constantly compare new level one codes to 

previously identified ones and then condense them into broader level II 

codes

Level III codes: theoretical constructs, most abstract, add scope beyond local 

meanings

Core category: pattern of behavior that is relevant and/or problematic for participants

Selective coding: can have 3 levels of abstraction, researchers code only those data that are related to the core variable

Basic social process (BSP): evolves over time in two or more phases, all BSP’s are core variables, but not all core variables have to be BSPs

Emergent fit: prevents individual substantive theories from being “respected little islands of knowledge”

Axial coding: analyst codes for context

Paradigm: used as an analytical strategy to help integrate structure and process

Central category: core category, which is the main theme of the research 

Initial coding: pieces of data (words, lines, segments, incidents) are studied so the researcher begins to learn what the participants view as problematic 

Focused coding: the analysis is directed toward using the most significant codes from the initial coding

Congruent methodological approach: analyzes interaction data in the same manner as a group or individual data 

Sociograms: can be used to understand the flow of conversation as it goes around the members of the focus group

Incubation: process of living the data, a process in which researchers must try to understand their meanings, find their essential patterns, and draw legitimate, insightful conclusions

Conceptual files: physical files in which coded excerpts of data relevant to specific categories are placed

Themes: involves the discovery nor only of commonalities across participants but also of natural variation and patterns in the data

Metaphors: figurative comparisons used to evoke a visual or symbolic analogy

Quasi-statistics: involves a tabulation of the frequency with which certain themes or relations are supported by the data

Qualitative content analysis: can vary in terms of an emphasis on manifest content or latent content and in the role of induction

Managing Qualitative Data

Computer-assisted qualitative data analysis software (CAQDAS): a program that can take uploaded data files, code the narratives, retrieve information, and display text for analysis

Within a qualitative data analysis there is not statistical tests, because qualitative research is based on thoughts, open ended questions, interpretations and interviews not numerical values. Data within qualitative research is understood and analyzed during the entirety of the process. “Researchers interpret the data as they read and reread them, categorize and code them, inductively develop a thematic analysis, and integrate the themes into a unified whole,” (Polit & Beck, 2017, p.549). There is not a step by step understanding of how the process occurs of interpreting the data, researchers “live” within the data by understanding the meanings, looking for patterns, draw valid, discerning conclusions. An additional importance of understanding of the facts is having the inventiveness to find the “aha” meaning of the information and discovery of the meanings of the facts gained (Polit & Beck, 2017). 

The importance of the interpretation is just as important as the validity of the data. Thorough and sensible researchers have a high standard of their data interpretation by dissecting themselves, peers and outside reviewers. It is vital that the qualitative researchers consider possible different explanations or meanings other than their own (Polit & Beck, 2017).

It is important nurses to understand statistical data because this is a large part of the work nurses base the practice on is evidence based, which means understanding the research behind the reason of the practice is important to understand. According to Hayat, it is important to understand the difference between statistical significance and clinical importance, researchers tend to use statistics to claim proof and scientific breakthrough. Significance testing can be used to decide which data may be considered evidence to support a practice change (2010). “Judgment and subjectivity are necessary and part of the decision-making process. Statistical significance is not a measure of importance; it is a subjective and qualitative construct. Researchers conducting quantitative analyses should quantify the magnitude of an effect. The value of the data collected should be assessed by examining study design, bias, and confounding variables, as well as meaningfulness of the results to the topic under study,” (Hayat, 2010, p.222). Nurses must consider this and have an understanding when utilizing statistical methods to base their practice changes. 

References

Hayat, M. J. (2010). Understanding Statistical Significance. Nursing Research, 59(3), 219–223

Polit, D.E. & Beck, C.T. (2017). Nursing Research: Generating and Assessing Evidence for Nursing 

Practice 10th ed. Philadelphia, PA: Wolters Kluwer

Sauro, J., (2015. October 13). Five types of qualitative methods, Retrieved from https://flic.kr/p/4PXXCYp.

By: Casey Hoffman, Tami Frazier, Sarah Pudenz, and Elizabeth Wilson

 

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Respond  of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.

                                               Main Post

                                  Sleep/Wake Disorders

The patient is an obese 70-year-old female with a chief complaint of “being sad.” Her husband passed away several years ago due to coronary artery disease (CAD). She lives at home alone and has a home health aide help her. Her son comes to visit her often. She was feeling well until her hearing began to diminish in both ears. Her mobility has declined, so she has not been able to get out as much. She is often lonely at home. She has daily crying spells, is often very tired, has good insight to her illness, and wants to get better. 

Three Questions to Ask the Patient and Why            

The case study mentioned that the patient is a candidate for cochlear implants, but it is a long way off. Thus, my first question to ask the patient is what is preventing her from getting cochlear implants?  

She began experiencing sadness when she began to lose her hearing and mobility. Therefore, regaining her hearing may help decrease the depression. If its financial reasons, maybe there are resources that can help her. Finding out the reason the patient isn’t getting the implants can help the provider and patient find solutions.             

The patient also mentioned that her sleep was “awful”, stating her legs “ache and jump”, she takes frequent naps during the day, and admits to snoring frequently. Thus, the second question I would ask is what are her sleeping habits like? 

Individuals who have good sleep habits sleep better. Getting better sleep can be obtained by being consistent by going to bed at the same time each night and waking up the same time each day (Centers for Disease Control and Prevention, [CDC], 2016).  Individuals can make sure the room is dark, quiet, and cool (CDC, 2016). Additionally, remove electronic devices, avoid large meals, caffeine, and alcohol can help with getting better sleep (CDC, 2016).              My third question would be what do you do when you are sad? Individuals who are depressed often have a negative view of the world and often think of themselves as worthless (This Way Up, n.d.). They often blame themselves when something bad happens and feel like they are unlucky (This Way Up, n.d.). Thus, helping individuals identify negative thinking and reframe the way they think about life can help improve depressive symptoms (This Way Up, n.d.). 

People to Speak to with Specific Questions to Ask 

The first person I would want to speak to is the patient’s son. The case study states the son visits her often so he should know the patient’s habits. First, I would ask him the same questions I asked the patient such as what is preventing the patient from getting cochlear implants, what are her sleep habits, and what does she do when she is sad? By asking the son the same questions, insight can be shown on how the son views things and how the patient views things. I would also him when he began to notice her depressive symptoms because that will help provide a timeline as to when it all began.             

The second person I would talk to is her home health aide because she is familiar with the patient. I would ask her what the patient’s home life is like such as how is she maintaining her house? Is she able to clean up after herself? How is she doing with activities of daily living? 

These questions can provide insight on the severity of the patient’s depressive symptoms. 

Physical Exams and Diagnostic Tests and How Results Would Be Used            

The first diagnostic test I would want to perform on the patient is the 9-item Patient Health Questionnaire (PHQ-9). The PHQ-9 is a screening tool for major depression (Na et al., 2018). The test is a reliable and valid measurement of depressive symptoms that also asks about the individual’s thoughts of death or self-injury within the last two weeks (Na et al., 2018). The results would be used to determine the severity of her depression. Another diagnostic test that can be performed on this patient is a polysomnography. A polysomnography is a sleep study that helps providers diagnose sleep apnea, periodic limb movement disorder, restless leg syndrome (RLS), insomnia, and nighttime behaviors (National Sleep Foundation, n.d.). The results would be used to can help determine the cause of her daytime sleepiness such as sleep apnea or RLS. I would also want to run a complete blood count (CBC) with differential on the patient. I would specifically want to obtain a red blood cell count (RBC) and white blood cell count (WBC). Thus, a CBC with differential would help determine if the patient is fatigued due to anemia or an underlying infection.

 Three Differential Diagnosis and Why

The three potential differential diagnoses include:Major Depressive DisorderPersistent Insomnia Disorder Obstructive Sleep Apnea Hypopnea The most likely differential diagnosis is major depressive disorder (MDD). The diagnostic criteria for MDD is five or more symptoms during the same 2-week period and a change from previous functioning (American Psychiatric Association, 2013).  The symptoms include: depressed mood most of the day, marked diminished interest or pleasure in all or almost all activities most of the day, significant weight loss or weight gain, insomnia or hypersomnia neatly every day, psychomotor agitation or retardation nearly every day, fatigue or loss of energy nearly every day, feelings of worthlessness or excessive or inappropriate guilt nearly every day, diminished ability to concentrate, and recurrent thoughts of death (American Psychiatric Association, 2013). The patient fits this diagnosis as evidence by depressed mood, diminished interest in activities she used to enjoy, fatigue, diminished ability to concentrate, and psychomotor retardation.

Two Pharmacological Agents and Dosing and Why 

One pharmacologic agent that can be tried is doxepin 3 mg at bedtime for insomnia. Doxepin works by boosting serotonin and norepinephrine by blocking the serotonin reuptake pump and norepinephrine reuptake pump (Stahl, 2017). At hypnotic doses, doxepin blocks histamine-1 receptors, which promotes sleep (Stahl, 2017). Doxepin is a substrate for CYP450 2D6 and has a half-life of 8-24 hours (Stahl, 2017). In the elderly, the recommended dose for insomnia is 3 mg per day (Stahl, 2017).             Another pharmacologic agent that I would like to start the patient on is bupropion (extended release) XL 150 mg daily in the morning. Bupropion is used to treat MDD and works by boosting norepinephrine and dopamine by blocking the norepinephrine reuptake pump and dopamine reuptake pump (Stahl, 2017). Bupropion inhibits CYP450 2D6, has a parent half-life of 10-14 hours, and a metabolite half-life of 20-27 hours (Stahl, 2017). Thus, since bupropion blocks the dopamine reuptake pump and norepinephrine reuptake pump, this medication is beneficial in improving symptoms of loss of happiness, joy, interest, pleasure, energy, enthusiasm, alertness, and self-confidence (Stahl, 2013). Thus, because of bupropion’s mechanism of action and the patient’s symptoms, I would want this patient to try this medication. 

Lessons Learned  

Lessons learned during this case study is that geriatric depression can be difficult to treat. They often have multiple comorbidities with the possibility of more pronounced side-effects (Stahl, 2008). Additionally, medications can have contraindications that do not previously exist prior to the patient being put on medication. Thus, providers must be aware of new and old warnings on medications in the event there are changes made to medications. I will apply this information when I am in practice by paying close attention to dosages, side effects, and potential contraindications when providing medication to the geriatric population. 

                                                  References

American Psychiatric Association. (2013). Diagnostic and statistical manual od mental disorders (5th ed.). Washington, DC: Author. Centers for Disease Control and Prevention. (2016). Tips for better sleep. Retrieved from https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.htmlNa, P. J., Yaramala, S. R., Kim, J. A., Kim, H., Goes, F. S., Zandi, P. P.,…Bobo, W. V. (2018). The PHQ-9 item 9 based screening for suicide risk: a validation study of the Patient Health Questionnaire (PHQ-9)-9 item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS). Journal of Affective Disorders, 232, 34-40. doi: https://doi.org/10.1016/j.jad.2018.02.045National Sleep Foundation. (n.d.). Sleep apnea. Retrieved from https://www.sleepfoundation.org/sleep-apneaThis Way Up. (n.d.). How do you feel? Retrieved from https://thiswayup.org.au/how-do-you-feel/sad/Stahl, S. M. (2008). Essential psychopharmacology online. Retrieved from https://stahlonline-cambridge-org.ezp.waldenulibrary.org/viewPdf?page=csEP_16.pdf&vol=2Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical    applications (4th ed.). New York, NY: Cambridge University Press. Stahl, S. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide (6th ed.). San Diego,  CA: Cambridge University Press. 

 

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Text and materials:

Ruth M. Tappen. (2015). Nursing Research. Advanced Nursing Research: From Theory to Practice. (2nd ed.). ISBN-13: 9781284048308. ISBN-10: 1284048306. Publisher: Jones & Bartlett Learning

Section VI: Middle Range Theories

Chapter 21: Katharine Kolcaba’s Comfort Theory 

Chapter 22: Joanne Duffy’s Quality-Caring Model

 

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Respond using one or more of the following approaches:

Ask a probing question, substantiated with additional background information, and evidence

Offer and support an alternative perspective using readings from the classroom or from your own review of the literature in the Walden Library.

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Reference:

Skloot, R. (2010). The immortal life of Henrietta Lacks. New York, NY: Crown Publishing Group.

                                                                      MAIN POST

                                          Ethical Dimensions of Research Studies

       Nursing research and research studies can offer many gains in the healthcare field and offer clear, conscience evidenced-based practices (EBP). Before diving into conducting a research study it is essential to understand ethical issues and ethical dilemmas. Research ethics demand necessity on daily work, the protection of test subject’s and the publicizing of information from the research (Fouka & Mantzorou, 2011). Ethical dilemmas are situations where the test subject’s rights are in conflict with the studies requirements (Polit & Beck, 2017). Nursing researcher need to be aware of any ethical issues and develop a research plan to help alleviate any problems or ethical dilemmas.

Transfusion of Prematures

       Transfusion of Prematures (TOP) Trial was an open, parallel-group multicenter randomized controlled trial (RCT) analyzed by the intention to treat (Kirpalani et al., 2012). The main point of the TOP trial was to determine whether higher hemoglobin levels for giving transfusions to extremely low birth weight infants could result in higher hemoglobin levels leading to the improvements in neurodevelopmental impairment at 22-26 months of age and the primary outcome to be survival (ClinicalTrials, 2019). The trial explained that by avoiding a breach the current practice boundaries of the hemoglobin levels that would require an infusion by using a transfusion algorithm. This would avoid dilemmas and minimize risks to the test subject’s. There are no real results of this trial. The test subject’s will be seen for follow-up visits at around six years old to assess neurological and functional outcomes based on the transfusion threshold (Kirpaplani et al., 2012).

Ethical Principles

       Three principles that standards of ethical conduct in research are based on are beneficence, respect for human dignity and justice (Polit & Beck, 2017). Beneficence can be explained as a duty to promote good and eliminate harm to the test subjects. The TOP trial was seen by the Institutional Review Board (IRB) as harmful by veering away from usual care and harmful risks were posed by the deviations (National Public Radio, 2013). The researcher could have maintained usual care and not deviate from routine care on the test subjects. The second ethical principle is respect for human dignity which is the right to know what will take place or full disclosure (Polit & Beck, 2017). The TOPS trial had defects and faced criticism for not telling all this risks that the subjects would face. In this trial the consent forms did not elaborate on previous studies about when to transfuse. The studies suggested that premature infants that had transfusions later had a higher chance of death, brain injury and emergency care for transfusions (National Public Radio, 2013). The researchers should have been honest to the test subject’s parents regarding the previous studies and the risks of participation in the study. The third principle is justice which allows for fair treatment and the right to have privacy (Polit & Beck, 2017). In the TOPS trial it was suggested that the subject’s parents were not aware of what was being asked. Parents were giving up their rights to a physician to make decisions on what they feel was in the best interest of the infant. This would impede on the right to fair treatment. The researchers need to make sure that the parents of the test subjects understand every aspect of the trial and have the rights to make decisions on what they feel is in the best interest of their child. The parent should have the say so in what is being done to their child and not a physician. Research can be done on sensitive issues while protecting the rights of the research subjects by following the ethical principles. Adopting the ethical principles will help avoid ethical dilemmas in research.

Conclusion

       Nursing research has many benefits to the practice and can produce evidence- based practices to help provide the best care to our patients. Ethical dilemmas can be avoided by conducting a study that poses minimal conflicts with patient rights. Making patient safety the main goal is essential in the success of a research study. Keeping ethical principles of beneficence, respect for human dignity, and justice intertwined in the development or framework of the study is the only way to ensure that participants are being protected.

 

  

References

ClinicalTrials. (2019). Transfusion of Prematures (TOP). Retrieved March 18, 2019, from http://www.clinicaltrials.gov/ct2/show/NCT01702805.

 

Fouka, G., & Mantzorou, M. (2011). What are the major ethical issues in conducting research? Is there a conflict between the research ethics and the nature of nursing? Health Science Journal, 5(1), 3-14. Retrieved from the Walden Library databases.

 

 

 

Kirpalani, H., Bell, H., D’Angio, C., Hintz, S., Kennedy, K., Ohls, R., Poindexter, B., Schibler, K., Schmidt, B., Vohr, B., Widness, J., Das, A., Higgins, R., Zupancic, J., Roberts, R., Whyte, R., Chaudhary, A., & Johnson, K. (2012). Transfusion of Prematures (TOP) Trial: Does a Liberal Red Blood Cell Transfusion Strategy Improve Neurologically-Intact Survival of Extremely-Low-Birth-Weight Infants as Compared to a Restrictive Strategy? Neonatal Research Network. Retrieved from http://www.nichd.nih.gov/sites/default/files/about/Documents/ TOP_Protocol.pdf.

 

National Public Radio (2013). Another Study of Preemies Blasted Over Ethical Concerns. Retrieved March 18, 2019, from http://www.npr.org/sections/health-shots/2013/08/23/214800726/another-study-of-preemies-blasted-over-ethical-concerns.

 

Polit, D.F., & Beck, C.T. (2017) Nursing Research Generating and Assessing Evidence for Nursing Practice (10th ed.). Philadelphia, PA: Wolters Kluwer.

 

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