Evidence Based Nursing Practice Group...

Running head EVIDENCE BASED NURSING PRACTICE GROUP PROJECT 1

Evidence Based Nursing Practice Group Project

Lai Harper Maggie Siler Gary Webster Jaime Ziemba

Ferris State University

NURS 350

EVIDENCE BASED NURSING PRACTICE GROUP PROJECT 2

Abstract

For adult patients in an acute care setting what does the literature reveal about the difference in

communication styles (collaboration interdisciplinary versus segmented authoritarian) between

physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes The

purpose of this Evidence-Based Nursing Practice group project is to critique the best peer-

reviewed research articles and answer this significant clinical question based on the hierarchy of

evidence Literature review has shown strong evidence for collaboration between physicians and

nurses at Magnet hospitals The evidence for training programs to improve communication skills

between physicians and nurses is applied to group membersrsquo nursing practice (cardiovascular

medicalsurgical oncology and general surgery)



Every day we have conversations between nurses and doctors What are the outcomes of

those conversations both positive and negative for patients and nurses Communication

between doctors and nurses can also affect patient safety If nurses cannot read orders written by

the doctors patient safety can be negatively affected If either the doctor or the nurse is having a

bad day heshe may take it out on the patient with improper body language or communication

Finally patientsrsquo safety can be affected by the type of hospital they are at Is it a larger magnet

hospital that can take care of all types of illness or is it a smaller non-magnet hospital that can

only stabilize and transfer the patient to a larger hospital

There are two types of professional communication verbal and nonverbal Verbal

communication is basic conversation of words that people say to one another These can be

simple words or technical jargon Verbal communication can be difficult if the nurse or doctor

has English as a second language or if the terms in the technical jargon are not shared by either

the doctor or nurse Nonverbal communication is body language and written communication

Both body language and written communication can be taken positively or negatively Positive

or negative nurse-physician relationships can have impacts on communication patient outcomes

and nursephysician job satisfaction (Schmalenberg amp Kramer 2009 p 77)

Communication between medical professionals is not a local problem It is a problem

found throughout the entire medical community This is evident by the many articles written and

studies done regarding the effect of professional communication on patient care


Literature Review

Our group initially evaluated eleven peer-reviewed research articles from the Agency for

Healthcare Research and Quality Cochrane Library and PubMedCINAHL databases The non-

cohesive communication between male authoritarian physicians and female subservient nurses

can result in two segmented groups at acute care hospitals (Ballou amp Landreneau 2010 p 75)

Using the qualitative ethnographic approach Gardezi et al (2009) analyzed at least 700 surgeries

for two years and reported communication conflicts due to nursesrsquo gap in knowledge and

surgeonsrsquo dominant authoritative power at three Canadian hospitals Nursesrsquo quietsubmissive

communication had potential damaging impacts on patient safety (pp 1394-1397) Hendel et

alrsquos (2007) study showed that charge nurses were more likely to reduce conflicts using the

ldquocollaborativerdquo communication style when compared to physicians at five Israeli hospitals (p

249)

Literature review has revealed the negative effects of dysfunctional communications in

acute care hospitals Manojlovich and DeCiccorsquos (2007) study showed that miscommunication

between physicians and nurses was statistically significant and positively associated with

perceived medication mistakes among 462 intensive care nurses at eight Michigan hospitals (p

452) Rosenstein and ODaniel (2008) reported that physician-nurse disturbing behaviors

(authoritarian communication verbal insult or disrespect) were likely to increase harmful

consequences such as medication errors and patientsrsquo deaths (p 464) Using the ldquoHamiltonrsquos

Anxiety Scalerdquo and ldquoStamprsquos Index of Work Satisfactionrdquo Karanikola et al (2012) investigated

the psychological and emotional health of 229 intensive care nurses at eleven hospitals in

Greece dissatisfaction in physician communication was statistically significant with

increased nursesrsquo stress levels (p 41)


The gender model for the authoritative dominance of physicians is not applicable to

advanced practice nursesAPNs which have high educational preparations (Rothstein and

Hannum 2007 p 235) A study has shown the statistical significance for APNsrsquo positive

attitudecommunication with female physicians (less than 50 years old) and male physicians (at

various ages) male and female physicians are also more likely to be respectful about APNsrsquo

knowledge and clinical decisions (Rothstein and Hannum p 238)

What are the evidence-based interventions for reducing authoritarian dysfunctional

communications and increasing interdisciplinary collaboration The Cochrane Database has

shown no randomized controlled studies about physician-nurse collaboration at acute care

hospitals (Zwarenstein Goldman amp Reeves 2009 p 8) The best four articles are selected

based on the hierarchy of evidence theoretical framework research methodology and

measurement instrument two ldquoLevel IIIrdquo quasi-experimental studies (Boone et al 2008

McCaffrey et al 2011) and two ldquoLevel Irdquo meta-analysisintegrated review (Kramer

Schmalenberg amp Maguire 2010 Schmalenberg amp Kramer 2009)

Analysis of Evidence

The first article ldquoConflict management training and nurse-physician collaborative

behaviorsrdquo (Boone King Gresham Wahl amp Suh 2008) is a quantitative quasi-experimental

study Ethical research guidelines are firmly adhered to This study uses a convenience sample

closely approximating the real world experience The purpose is to examine a knowledge gap

between unit specific interventions and improved communication and collaboration The

importance of improving quality of care and nurse satisfaction through respectful communication

and collaboration is the basis for this study The impact of conflict management training on

nurse-physician communication and collaboration is analyzed Theoretical framework is based


on ldquoKilmann and Thomas conflict resolution theoryrdquo (Boone et al p 168) The instrument

Collaborative Behavior Scale (CBS) is valid and reliable with a Cronbach alpha score of 076-

097 (Boone et al 2008 p 169) Unexpectedly the null hypothesis was not rejected The

intervention was statistically insignificant with both study and control group mean CBS scores

pre and post intervention pgt05 (Boone et al pg 172) Several limitations are identified

Continued research for interventions to promote quality communication and collaboration is a

significant step toward creating a culture that supports healthy work environments The level of

evidence for this article could be identified as II (Johns Hopkins Nursing Evidence Based

Practice Research Evidence Appraisal nd C Bongiorno personal communication November

26 2012) or III (Ford 2012) Both are credible for use in evidence based practice

There are many tools available for the evaluation of evidence in nursing research

(Nieswiadomy 2012 p 284) A senior hospital research specialist was consulted to review our

evaluation methods (C Bongiorno personal communication November 26 2012) Course

modules and a tool from Johns Hopkins are applied to the appraisal of evidence in this paper

The second article ldquoNine structures and leadership practices essential for a magnetic

(healthy) work environmentrdquo (Kramer Schmalenberg amp Maguire 2012) is a quantitative meta-

analysis of thirty professional publications to identify structures and leadership practices

necessary to support a healthy work environment The results of over 1300 interviews (good

sample size) of expert nurses nurse managers and physicians were compiled and compared to

results from regulatory and professional organizations The theoretical framework is based on

the Donabedian model of patient safety (Medical Teamwork and Patient Safety nd) which

assesses quality of care by evaluating structures processes and outcomes Results of the meta-

analysis revealed comparable findings from expert interviews and regulatoryprofessional


organizations as to what structures and leadership practices yielded a healthy work environment

(HWE) HWErsquos are defined as places where ldquoclinical nurses can execute the work processes and

establish the relationships essential to the provision of quality patient carerdquo (Kramer et al 2012

p 12) Creating a culture of interdisciplinary collaboration and teamwork through shared power

and administrative support were common themes This is a level I research study for evidence

based practice (Ford 2012 JHNEBP Research Evidence Appraisal nd C Bongiorno

personal communication November 26 2012)

The third article chosen ldquoThe effect of an educational programme [sic] on attitudes of

nurses and medical residents towards the benefits of positive communication and collaborationrdquo

(McCaffery et al 2012) is a quasi-experimental study exploring how an educational programme

[sic] could positively affect communication and collaboration between nurses and medical

residentrsquos A convenience sample and pre and post-test design were utilized to test the

hypothesis Ethical research guidelines are carefully adhered to Instruments used to measure

the attitudes of nurses and residents were the ldquoJefferson Scale of Attitudes towards Physician-

Nurse Collaborationrdquo and the ldquoCommunication Collaboration and Critical Thinking for Quality

Patient Outcomes Surveyrdquo (McCaffery et al 2012 p 297) Both instruments were proven

reliable utilizing the Cronbach alpha test (scores 087-092) (McCafferyet al p298) The

literature review is logical sequential and thorough A critical finding of this study is that

ldquoEffective communication is the cornerstone of interdisciplinary collaborationrdquo (McCaffery et

al 2012 p 294) Statistical findings revealed positive pre and post- test differences for both

nurses and medical residents with p values ranging from 0000 to 0001 demonstrating positive

results with the intervention (McCaffery et al pg 298) Due to the lack of a control group the

evidence level for this study is III (Ford 2012 C Bongiorno personal communication


November 26 2012) Alternatively this study is rated as evidence level II by the Johns Hopkins

scale (JHNEBP Research Evidence Appraisal nd) as it is quasi-experimental Both levels are

acceptable for application to evidence based practice

The fourth article utilized is ldquoNurse-physician relationships in hospitals 20000 nurses

tell their storyrdquo (Schmalenberg amp Kramer 2009) This study is a quantitative synthesis of

findings from six research studies which evaluated the problem of how nurses ldquoperceive assess

and develop high quality relationships with physicians in hospitals with the goal of improving

patient carerdquo (Schmalenberg amp Kramer 2009 p 74) An excellent sample size of 20616 staff

nurses defined five types of nurse-physician interactions (collegial collaborative student-

teacher friendly stranger and hostileadversarial) that occur in nearly all clinical settings High

quality nurse-physician interactions directly affect patient care and organizational outcomes

(decreased costs and improved patient nurse and physician satisfaction) Nurse-physician

relationships were further compared at magnet and non-magnet institutions It was consistently

found that nurses practicing at magnet hospitals report higher quality nurse-physician

relationships than nurses in comparison hospitals Three structures that can improve nurse-

physician relationships are to keep patient needs first develop constructive conflict resolution

techniques and establish collaborative interdisciplinary patient rounds As this study is a double

blinded peer review and a synthesis of six research studies it is clearly level I evidence by all

methods (Ford 2012 JHNEBP Research Evidence Appraisal nd C Bongiorno personal

communication November 26 2012)


Application of Evidence

Jaime

MedicalSurgical units rely on effective communication between doctors and nurses to

ensure that patients are safe and well taken care of Doctors and nurses need to look to each

other to treat the patient as a whole and make sure that their stay in the hospital is short lived and

that the patients will not return within a week

Many medicalsurgical nurses where I work are faced with working several 12 hour

shifts in a row Our patient census has exceeded 14 (which is well over our units allotted beds)

and we are faced with doctors who just donrsquot listen to the nursing staff The McCaffrey et al

article is accurate for my hospital We are starting to have monthly meetings between nursing

and supervisors for follow up on nursedoctor relationships The doctors meet monthly with

each other and our director of nursing to discuss communicationrelationships

In my job as Utilization Review I need to have very effective communication with all

doctors Each day I sit down with the doctors and we go over patient by patient I must

communicate with them when a person is meeting or is not meeting criteria to be in the hospital

I also must communicate some ways they can make the patient meet criteria if the doctor wants

to keep them an extra day At first the doctors were not too keen on a nurse telling ldquowhat to dordquo

but over the past several months it has gotten better and they are even communicating with me

before a patient is admitted from the ER We are both trying to work together for the better of each and

every patient in our hospital

Gary

Intra-operative settings place nurses and physicians in close collaborative work settings

The typical communication style is authoritarian The doctors choose the procedure positioning


prep technique start and stop times Schmalenberg and Kramerrsquos article stated that physicians

felt the nurse-physician relation to be more collaborative than nurses did I can see that being

true in my work environment Nurses may suggest something by asking a question but we do not

have the freedom to make care changes or suggestions The Boone et al (2008) and McCaffrey

(2011) articles combined are very valuable Together the articles show a successful attempt to

increase collaboration and some pitfalls that could result in failure to increase collaboration

These can help direct any programs to support an increase in collaboration

Lai

At an oncology unit nurses can utilize the Cochrane Database and the ldquoJohn Hopkins

Research Evidence Appraisalrdquo as the tools to communicate and collaborate with oncologist about

the evidence-based practice Ongoing literature review for the most credible interventions is

essential for improving oncology patientsrsquo physical psychological and emotional well-being

The hospital nursing research committee is recommended to initiate a survey about possible

communication barriers between nurses and physicians The McCaffrey et al (2012) training

program provides great perspectives for reducing dysfunctional communication (p 293) The

low-cost convenient computer-based training in physician-nurse communication skills can be

implemented due to the challenging schedules for attending the classroom training

Maggie

High quality communication and strong collaborative skills with physicians and peers

make a great difference in the cardiac catheterization laboratory (CCL) (Boone King Gresham

Wahl amp Suh 2008 p 168) Long experience and a broad knowledge base bring a high level of

confidence to my work both are critical to collaborative relationships and clinical autonomy


(Schmalenberg amp Kramer 2009 p 82) The value of collaborative practice is vital to each

patient physician and nurse as well as the entire healthcare system Benefits include decreased

hospital stays improved patient outcomes and nurse-physician job satisfactionretention (Kramer

et al 2012 p 7) Barriers faced in my work setting are the fast pace occasional extreme hours

and less than optimal nurse-nurse and unit-unit communication Improving communication

through evidence based educational methods (McCaffery et al 2012) is possible but could be

expensive A few less expensive options may include bidirectional staff shadowing with partner

units to better understand each arearsquos needs and processes improved interaction of our Unit

Action Councils (UACrsquos) to increase unit-unit communication and effective staffprocedure

scheduling to help ensure extreme hours are the exception

Summary

The purpose of this project was to answer this question For adult patients in an acute

care setting what does the literature reveal about the difference in communication styles

(collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses

on indicators of nurse satisfaction rates and patient safety outcomes The selected articles did

not address every aspect of the preceding question but were able to be combined as quality

evidence for this topic

Schmalenberg and Kramerrsquos 2009 literature review shows collaboration as the best way

for professionals to communicate Kramer et alrsquos literature on healthy work environments shows

the importance of supporting collaboration to develop a healthy work environment McCaffrey

et al (2011) and Boone et al (2008) address the importance of increased education for proper

collaboration to occur Unfortunately the results were different for each study Nevertheless


the articles show two different educational based attempts to increase interdisciplinary

communication and collaboration

Collaboration is the goal for interdisciplinary communication The current literature and

studies are able to help direct further research Development of education to increase

collaboration for all disciplines is required Creation of working environments that foster

collaboration is necessary Future studies can test methods to increase education as well as ways

to incorporate those methods into current working environments


Appendix

JHNEBP Research Evidence AppraisalEvidence Level

ARTICLE TITLE NUMBER

AUTHOR(S) DATE

JOURNAL

SETTING SAMPLE (COMPOSITIONSIZE)

Experimental

Meta-An

alysis

Quasi-exp

erimental

Non-experimen

tal

Qualitative Meta- Synthesis

Does this study apply to the population targeted by my practice question Yes No

If the answer is No STOP here (unless there are similar characteristics)

Strength of Study Design Was sample size adequate and appropriate

Yes No

Were study participants randomized Yes

No Was there an intervention

Yes No

Was there a control group Yes

No If there was more than one group were groups equally treated except

for the intervention Yes

No

Was there adequate description of the data collection methods Yes

No

Study Results Were results clearly presented Yes No Was an interpretationanalysis provided Yes No

Study Conclusions Were conclusions based on clearly presented results Yes No Were study limitations identified and discussed Yes NoPERTINENT STUDY FINDINGS AND RECOMMENDATIONS

Will the results help in caring for my patients Yes No


Evidence Rating (scales on separate sheet)Strength of EvidenceQuality of Evidence (check one) High (A) Good (B) LowMajor flaw (C)

JHNEBP Research Evidence Appraisal (continued)STRENGTH OF EVIDENCELEVEL 1 (HIGHEST)EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)bull Study participants (subjects) are randomly assigned to either a treatment (TX) or control(non-treatment) groupbull May beo Blind neither subject nor investigator knows which TX subject is receivingo Double-blind neither subject nor investigator knows which TX subject is receivingo Non-blind both subject and investigator know which TX subject is receiving usedwhen it is felt that the knowledge of treatment is unimportantMETA-ANALYSIS OF RCTSbull Quantitatively synthesizes and analyzes results of multiple primary studies addressing asimilar research questionbull Statistically pools results from independent but combinable studiesbull Summary statistic (effect size) is expressed in terms of direction (positive negative orzero) and magnitude (high medium small)LEVEL 2QUASI-EXPERIMENTAL STUDYbull Always includes manipulation of an independent variablebull Lacks either random assignment or control groupbull Findings must be considered in light of threats to validity (particularly selection)LEVEL 3NON-EXPERIMENTAL STUDYbull No manipulation of the independent variablebull Can be descriptive comparative or relationalbull Often uses secondary databull Findings must be considered in light of threats to validity (particularly selection lack ofseverity or co-morbidity adjustment)QUALITATIVE STUDY1048707 Explorative in nature such as interviews observations or focus groups1048707 Starting point for studies of questions for which little research currently exists1048707 Sample sizes are usually small and study results are used to design stronger studies thatare more objective and quantifiableMETA-SYNTHESIS1048707 Research technique that critically analyzes and synthesizes findings from qualitativeresearch1048707 Identifies key concepts and metaphors and determines their relationships to each other1048707 Aim is not to produce a summary statistic but rather to interpret and translate findingsQUALITY RATING (SCIENTIFIC EVIDENCE)A High quality consistent results sufficient sample size adequate control anddefinitive conclusions consistent recommendations based on extensive literaturereview that includes thoughtful reference to scientific evidenceB Good quality reasonably consistent results sufficient sample size some controland fairly definitive conclusions reasonably consistent recommendations based


on fairly comprehensive literature review that includes some reference toscientific evidenceC Low quality or major flaws little evidence with inconsistent results insufficientsample size conclusions cannot be drawn

JHNEBP Research Evidence Appraisal

References

Ballou K amp Landreneau K (2010) The authoritarian reign in American health care Policy

Politics amp Nursing Practice 11(1) 71-79 doi1011771527154410372973

Boone B King M Gresham L Wahl P amp Suh E (2008) Conflict management training

and nurse-physician collaborative behaviors Journal For Nurses In Staff Development

24(4) 168-175 doi10109701NND00003206705641591

Ford L (2012) Week 8 amp 9 Critique of Research Retrieved from

httpsfsulearnferriseduwebappsportalframesetjsptab_tab_group_id=_2_1ampurl=2F

webapps2Fblackboard2Fexecute2Flauncher3Ftype3DCourseampid3D_

2241_1ampurl3D

Gardezi F Lingard L Espin S Whyte S Orser B amp Baker G (2009) Silence power and

communication in the operating room Journal Of Advanced Nursing 65(7) 1390-1399

doi101111j1365-2648200904994x

Hendel T Fish M amp Berger O (2007) Nursephysician conflict management mode choices

implications for improved collaborative practice Nursing Administration Quarterly

31(3) 244-253

John Hopkins UniversityJohn Hopkins Hospital (nd) JHNEBP Research Evidence Appraisal

Retrieved from httpwwwnursingworldorgDocumentVaultNursingPracticeResearch-

ToolkitJHNEBP-Research-Evidence-Appraisalpdf

Karanikola M Papathanassoglou E Kalafati M Stathopoulou H Mpouzika M amp


Goutsikas C G (2012) Exploration of the Association Between Professional

Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel

Dimensions Of Critical Care Nursing 31(1) 37-45

doi101097DCC0b013e31823a55b8

Kramer M Schmalenberg C amp Maguire P (2010) Nine structures and leadership practices

essential for a magnetic (healthy) work environment Nursing Administration Quarterly

34(1) 4-17 doi101097NAQ0b013e3181c95ef4

Manojlovich M amp DeCicco B (2007) Healthy work environments nurse-physician

communication and patients outcome American Journal Of Critical Care 16(6) 536-

543

McCaffrey R Hayes R Cassell A Miller-Reyes S Donaldson A amp Ferrell C (2012)

The effect of an educational programme on attitudes of nurses and medical residents

towards the benefits of positive communication and collaboration Journal Of Advanced

Nursing 68(2) 293-301 doi101111j1365-2648201105736x

Medical teamwork and patient safety (nd) Retrieved November 2 2012 from

httpwwwahrqgovqualmedteammedteamfig2htm

Nieswiadomy R M (2012) Foundations of Nursing Research (6th Ed) Upper Saddle River

New Jersey Prentice Hall

Rosenstein A amp ODaniel M (2008) A survey of the impact of disruptive behaviors and

communication defects on patient safety Joint Commission Journal On Quality amp

Patient Safety 34(8) 464-471

Rothstein W amp Hannum S (2007) Profession and gender in relationships between advanced

practice nurses and physicians Journal Of Professional Nursing 23(4) 235-240


doi101016jprofnurs200701008

Schmalenberg C amp Kramer M (2009) Nurse-physician relationships in hospitals 20 000

nurses tell their story Critical Care Nurse 29(1) 74-83 doi104037ccn2009436

Zwarenstein M Goldman J amp Reeves S (2009) Interprofessional collaboration Effects of

practice-based interventions on professional practice and healthcare outcomes Cochrane

Database Of Systematic Reviews (3) 1-31 doi10100214651858CD000072


Abstract

For adult patients in an acute care setting what does the literature reveal about the difference in

communication styles (collaboration interdisciplinary versus segmented authoritarian) between

physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes The

purpose of this Evidence-Based Nursing Practice group project is to critique the best peer-

reviewed research articles and answer this significant clinical question based on the hierarchy of

evidence Literature review has shown strong evidence for collaboration between physicians and

nurses at Magnet hospitals The evidence for training programs to improve communication skills

between physicians and nurses is applied to group membersrsquo nursing practice (cardiovascular

medicalsurgical oncology and general surgery)























Literature Review











249)











































































































Jaime



















Gary











Lai










Maggie
















Summary





















Appendix



AUTHOR(S) DATE

JOURNAL


Experimental

Meta-An

alysis

Quasi-exp

erimental

Non-experimen

tal





Yes No



Yes No




No


No










References





24(4) 168-175 doi10109701NND00003206705641591




2241_1ampurl3D



doi101111j1365-2648200904994x



31(3) 244-253









doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x







































Literature Review











249)











































































































Jaime



















Gary











Lai










Maggie
















Summary





















Appendix



AUTHOR(S) DATE

JOURNAL


Experimental

Meta-An

alysis

Quasi-exp

erimental

Non-experimen

tal





Yes No



Yes No




No


No










References





24(4) 168-175 doi10109701NND00003206705641591




2241_1ampurl3D



doi101111j1365-2648200904994x



31(3) 244-253









doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x
















































































































Jaime



















Gary











Lai










Maggie
















Summary





















Appendix



AUTHOR(S) DATE

JOURNAL


Experimental

Meta-An

alysis

Quasi-exp

erimental

Non-experimen

tal





Yes No



Yes No




No


No










References





24(4) 168-175 doi10109701NND00003206705641591




2241_1ampurl3D



doi101111j1365-2648200904994x



31(3) 244-253









doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x

























Lai










Maggie
















Summary





















Appendix



AUTHOR(S) DATE

JOURNAL


Experimental

Meta-An

alysis

Quasi-exp

erimental

Non-experimen

tal





Yes No



Yes No




No


No










References





24(4) 168-175 doi10109701NND00003206705641591




2241_1ampurl3D



doi101111j1365-2648200904994x



31(3) 244-253









doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x




























Summary





















Appendix



AUTHOR(S) DATE

JOURNAL


Experimental

Meta-An

alysis

Quasi-exp

erimental

Non-experimen

tal





Yes No



Yes No




No


No










References





24(4) 168-175 doi10109701NND00003206705641591




2241_1ampurl3D



doi101111j1365-2648200904994x



31(3) 244-253









doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x


























Appendix



AUTHOR(S) DATE

JOURNAL


Experimental

Meta-An

alysis

Quasi-exp

erimental

Non-experimen

tal





Yes No



Yes No




No


No










References





24(4) 168-175 doi10109701NND00003206705641591




2241_1ampurl3D



doi101111j1365-2648200904994x



31(3) 244-253









doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x























References





24(4) 168-175 doi10109701NND00003206705641591




2241_1ampurl3D



doi101111j1365-2648200904994x



31(3) 244-253









doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x





















doi101097DCC0b013e31823a55b8



34(1) 4-17 doi101097NAQ0b013e3181c95ef4



543




Nursing 68(2) 293-301 doi101111j1365-2648201105736x

















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