1
|
Weaver SH, Hessels AJ, Paliwal M, Wurmser TA. From dusk to dawn: A healthy work environment for nurses working night shift. Nurs Manag (Harrow) 2023; 54:18-27. [PMID: 36998184 DOI: 10.1097/01.numa.0000921912.36370.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Affiliation(s)
- Susan H Weaver
- Susan H. Weaver is a nurse scientist at Hackensack Meridian Health Ann May Center for Nursing in Neptune, N.J., and the New Jersey Collaborating Center for Nursing in Newark, N.J. Amanda J. Hessels is an assistant professor at Columbia University School of Nursing in New York, N.Y., and a nurse scientist at Hackensack Meridian Health Ann May Center for Nursing in Neptune, N.J. Mani Paliwal is a senior biostatistician at Hackensack Meridian Health , Institute for Evidence Based Care in Edison, N.J. Theresa A. Wurmser is the vice president of nursing research, grants and academic affairs at Hackensack Meridian Health Ann May Center for Nursing in Neptune, N.J., the dean of the Georgian Court-Hackensack Meridian Health School of Nursing in Lakewood, N.J., and a member of the Nursing Management Editorial Board
| | | | | | | |
Collapse
|
2
|
Weaver SH, de Cordova PB, Vitale TR, Hargwood P, Salmond S. Experiences and perceptions of nurses working night shift: a qualitative systematic review. JBI Evid Synth 2023; 21:33-97. [PMID: 35975311 DOI: 10.11124/jbies-21-00472] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The objective of this review was to examine the available evidence on the experiences and perceptions of nurses working the night shift within any specialty in the acute care, subacute, or long-term care setting. INTRODUCTION Nurses are required for around-the-clock patient care. Night shift nurses can experience detrimental effects because of their work hours, which disrupt their normal circadian rhythm. Understanding nurses' experiences and perceptions when working night shift will facilitate the development of strategies to minimize the potential negative effects of working at night. In examining nurses' experiences and perceptions of working night shift, there is scope to explore how to improve night shift nurses' practice environment and job satisfaction, which will then translate to improved nurse and patient outcomes. INCLUSION CRITERIA This review included qualitative studies focused on the experiences and perceptions of registered nurses and licensed practical nurses who work the night shift or rotate between day and night shift. METHODS This review followed the JBI methodology for systematic reviews of qualitative evidence. The methodology used was consistent with the a priori protocol. Studies included in this review were those published in full text, English, and between 1983 (when the seminal work on hospitals that attract and retain nurses was published) and February 2021, when the search was completed. The main databases searched for published and unpublished studies included MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science.From the search, two reviewers independently screened the studies against the inclusion criteria, and then papers selected for inclusion were assessed for methodological quality. Qualitative data were extracted from the included papers independently by the four reviewers. Results from each reviewer were discussed and clarified to reach agreement. The extracted findings were pooled and examined for shared meaning, coded, and grouped into categories. Common categories were grouped into meta-synthesis to produce a comprehensive set of synthesized findings. The final synthesized findings were graded using the ConQual approach to determine the level of confidence (trust) users may have in the value of the synthesized findings. RESULTS Thirty-four papers, representing 33 studies, met the criteria for inclusion. The studies were conducted in 11 countries across six continents, with a total of 601 participants. From these, a total of 220 findings were extracted and combined to form 11 categories based on similarity in meaning, and three syntheses were derived: i) The "Other" Shift: the distinctiveness of night nursing; ii) Juggling sleep and all aspects of life when working nights; and iii) Existing in the Twilight Zone: battling the negative impact of sleep deprivation consumes nurses who strive to keep patients, self, and others safe. CONCLUSIONS The major conclusions from this review are the uniqueness of working the night shift and the sleep deprivation of night nurses. Organizational strategies and support are needed for those working this shift, which will enhance nurse and patient safety. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019135294.
Collapse
Affiliation(s)
- Susan H Weaver
- Hackensack Meridian Health, Ann May Center for Nursing, Neptune, NJ, USA.,School of Nursing, Rutgers, the State University of New Jersey, Newark, NJ, USA
| | - Pamela B de Cordova
- School of Nursing, Rutgers, the State University of New Jersey, Newark, NJ, USA
| | - Tracy R Vitale
- School of Nursing, Rutgers, the State University of New Jersey, Newark, NJ, USA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Susan Salmond
- School of Nursing, Rutgers, the State University of New Jersey, Newark, NJ, USA.,The Northeast Institute for Evidence Synthesis and Translation (NEST): A JBI Centre of Excellence, Rutgers, The State University of New Jersey, Newark, NJ, USA
| |
Collapse
|
3
|
Nurmeksela A, Mikkonen S, Kinnunen J, Kvist T. Validation of the Nurse Managers' Work Content Questionnaire and Factors-A Structural Equation Modeling Study. J Nurs Res 2022; 30:e245. [PMID: 36301852 DOI: 10.1097/jnr.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The responsibilities of nurse managers are diverse and occasionally inadequately organized. Moreover, the role of nurse manager often lacks a clear job description. Few methodologies for evaluating the content of nurse managers' work exist. PURPOSE This study was designed to validate the Nurse Managers' Work Content Questionnaire (NMWCQ) instrument and to analyze the relationships between NMWCQ factors and background variables using structural equation modeling. METHODS A multicenter descriptive and cross-sectional study design was used. The NMWCQ, which includes 87 items across 13 components, was developed based on a comprehensive literature review and pilot study. The questionnaire was sent to all of the nurse managers ( N = 756) employed at eight Finnish hospitals in 2019. Exploratory and confirmatory factor analyses were used to psychometrically test and validate the NMWCQ, whereas Cronbach's alpha values were calculated to explore the internal consistency of the instrument. Structural equation modeling was applied to detect the relationships between the constructed factor structure and the background variables. RESULTS Two hundred seven nurse managers participated in this study. The final solution for the NMWCQ included 75 items across 12 factors. The NMWCQ factors were as follows: responsibility for new employees, daily management, human resource management, decision making, clinical nursing, development, planning of processes, collaboration, ensuring knowledge, evidence-based management, ensuring care quality, and financial management. The items showed factor loadings that were either positive or negative, with values ranging from .314 to .846. The Cronbach's alpha values for the factors ranged between .605 and .851. All of the covariances and relationships between background variables and factors were found to be significant ( p ≤ .05). The structural equation modeling showed acceptable index results (incremental fit index = .954, comparative fit index = .951, and root mean square error of approximation = .048). CONCLUSIONS The NMWCQ version assessed in this study shows a more robust structure than the previously published pilot version. Psychometric testing showed the NMWCQ as suitable for describing the diverse work requirements of nurse managers and may offer a framework for concretizing the job description of nurse managers.
Collapse
Affiliation(s)
- Anu Nurmeksela
- PhD, RN, Lecturer, Department of Nursing Science, Faculty of Health Sciences, University of Eastern, Finland
| | - Santtu Mikkonen
- PhD, Senior Researcher and Statistician, Department of Applied Physics, and Department of Environmental and Biological Sciences, University of Eastern Finland, Kuopio Campus, Finland
| | - Juha Kinnunen
- PhD, Director, Health Care District, Central Finland Central Hospital, Finland
| | - Tarja Kvist
- PhD, RN, Professor and Head, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland
| |
Collapse
|
4
|
Clinical nurse managers and administrative supervisors: An experimental comparison. Nursing 2022; 52:50-54. [PMID: 36259908 DOI: 10.1097/01.nurse.0000884772.72980.cd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
5
|
ReSEARCH Your Passion. JOURNAL OF INFUSION NURSING 2021; 44:196-197. [PMID: 34197348 DOI: 10.1097/nan.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
6
|
Weaver SH, de Cordova PB, Vitale TR, Salmond S. Experiences and perceptions of nurses working night shift: a qualitative systematic review protocol. JBI Evid Synth 2021; 18:1278-1284. [PMID: 32813375 DOI: 10.11124/jbisrir-d-19-00187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this qualitative systematic review is to examine the available evidence on the experiences of nurses working the night shift within any specialty in the acute care, subacute, or long-term care setting. INTRODUCTION Nurses are required for round-the-clock patient care, and night shift nurses can experience detrimental effects as a result of their work hours. Understanding nurses' experiences when working night shift will facilitate the development of strategies to minimize the potential negative effects of working at night. In examining nurses' perceptions of working night shift, there is scope to explore how to improve night shift nurses' practice environment and job satisfaction, which will then translate to improved patient outcomes. INCLUSION CRITERIA This review will consider qualitative studies that include registered nurses and licensed practical nurses who work night shift or rotate between day and night shift. Night supervisors and advanced practice nurses will be excluded due to the potential for dissimilar experiences and resources within those groups. The search will be limited to studies published in English from 1983 to the present. METHODS The search strategy is designed to locate both published and unpublished qualitative studies by searching academic databases for published studies, gray literature, and hand searching reference lists. The study selection, critical appraisal, data extraction, and synthesis for this systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019135294.
Collapse
Affiliation(s)
- Susan H Weaver
- Hackensack Meridian Health, Ann May Center for Nursing, Neptune, USA.,Rutgers, the State University of New Jersey, School of Nursing, Newark, USA
| | | | - Tracy R Vitale
- Rutgers, the State University of New Jersey, School of Nursing, Newark, USA
| | - Susan Salmond
- Rutgers, the State University of New Jersey, School of Nursing, Newark, USA.,The Northeast Institute for Evidence Synthesis and Translation (NEST): A JBI Centre of Excellence
| |
Collapse
|
7
|
Nurmeksela A, Mikkonen S, Kinnunen J, Kvist T. Relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors at the unit level: a correlational study. BMC Health Serv Res 2021; 21:296. [PMID: 33794875 PMCID: PMC8017674 DOI: 10.1186/s12913-021-06288-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 03/17/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Nurse managers play a critical role in enhancing nursing and patient outcomes. The work of nurse managers, who can be described as middle-managers at health care organizations, is complex and changes on a daily basis. Only a few studies have clarified how nurse managers divide their time across various work activities. This study aimed to describe the relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors at the hospital unit level. METHODS A cross-sectional and correlational study design was used. The data were collected from nurse managers (n = 29), nursing staff (n = 306), and patients (n = 651) from 28 units across three Finnish acute care hospitals between April and November 2017. In addition, data concerning medication errors (n = 468) over one calendar year (2017) were acquired from the hospitals' incident reporting register. Analysis of covariance (ANCOVA) was used to estimate relationships between data from subareas of Nurse Managers' Work Content Questionnaire, Kuopio University Hospital Job Satisfaction Scale, and Revised Humane Caring Scale, along with medication error reports. A significance level of 95% was applied when estimating the covariances between variables. Unstandardized regression coefficients (B) were used to explain the relationships between variables. RESULTS Multiple relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors were identified. Nurse managers' work activities had both positive and negative relationships on the other studied variables. The Requiring factors of work (p < .001) subarea of nurses' job satisfaction, total patient satisfaction (p < .001), and medication errors (p < .001) were identified as the variables most significantly affected by other factors. CONCLUSIONS The findings suggest that nurse managers should focus on improving nursing practices by managing and organizing nurses' work in a way that makes their employees feel supported, motivated and secure. Furthermore, nurse managers should adopt a leadership style that emphasizes safe and patient-centered care. The results also suggest that the administration of today's health care organizations should actively evaluate nurse managers' share of work activities to ensure that their daily work is in line with the organizational goals.
Collapse
Affiliation(s)
- Anu Nurmeksela
- Faculty of Health Sciences, Department of Nursing Science, University Teacher, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
| | - Santtu Mikkonen
- Department of Applied Physics and Department of Environmental and Biological Sciences, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
| | - Juha Kinnunen
- Central Finland Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland
| | - Tarja Kvist
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio Campus, P.O. Box 1627, 70211 Kuopio, Finland
| |
Collapse
|
8
|
Laverde Contreras OL, Sanchez Herrera B. Fortalecer la coordinación de enfermería para mejorar el cuidado hospitalario. REVISTA CUIDARTE 2020. [DOI: 10.15649/cuidarte.826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introducción: La coordinación adecuada para organizar la atención de enfermería a nivel hospitalario es decisiva frente al servicio que se ofrece a los sujetos de cuidado y al mejoramiento permanente de la institución. Objetivo: Describir qué dice la literatura mundial sobre cómo fortalecer el rol de coordinación de enfermería a nivel hospitalario. Materiales y Métodos: Búsqueda integradora de literatura bajo parámetros de Ganong, con publicaciones arbitradas, observación de seis años, sin límites geográficos, en idiomas inglés, español y portugués. Resultados: De acuerdo con la literatura surgen tres categorías que incluyen: características del rol de coordinador de enfermería; impacto de esta coordinación en los resultados frente al sujeto de cuidado; y estrategias para fortalecer el rol de coordinación dentro de la institución. La evidencia que respalda el desarrollo de la coordinación de enfermería en el hospital es débil, con una mayoría de estudios de tipo descriptivo. Discusión: La coordinación de enfermería debe articular la dirección y la operación en el hospital y para ello requiere conocer y acompañar la directriz institucional a mediano y largo plazo y manejar estrategias de motivación y acompañamiento para facilitar su logro. Conclusiones: En una institución hospitalaria, la enfermera coordinadora debe mantener el norte en medio de la cotidianeidad de la asistencia; acompañar y motivar al personal a su cargo mediante competencias de liderazgo, trabajo en equipo y conocimiento clínico e institucional. Requiere para el ejercicio de su rol, proyectar el cambio y mantener un pensamiento integrador.
Como citar este artículo: Laverde Contreras Olga Lucia, Sánchez Herrera Beatriz. Fortalecer la coordinación de enfermería para mejorar el cuidado hospitalario. Revista Cuidarte. 2020; 11(2): e826. http://dx.doi.org/10.15649/cuidarte.826
Collapse
|
9
|
Nurmeksela A, Kinnunen J, Kvist T. Nurse managers' work content: development of the questionnaire and results of the pilot study. Scand J Caring Sci 2019; 34:839-851. [PMID: 31750557 DOI: 10.1111/scs.12796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022]
Abstract
AIM To develop the Nurse Managers' Work Content Questionnaire (NMWCQ) and to describe nurse managers' work content. BACKGROUND Restructuring within health care has expanded the nurse manager's role to include organisational, patient and staff demands. METHODS The pilot study employed a cross-sectional study design. Based on a literature review, the NMWCQ with 102 items was developed and pretested for this study. Data were collected in 2017 from three Finnish acute care central hospitals that provide specialised health care. A total of 61 nurse managers participated, which represents a response rate of 59%. Principal component analysis was used to test the construct validity of the instrument. Cronbach's alpha values were used to analyse the internal consistency of the instrument. In addition, descriptive and nonparametric analysis was used. RESULTS Ultimately, 13 components with 87 items were identified in the questionnaire. The construct validity and internal consistency of the questionnaire were at acceptable levels. Cronbach's alpha rates of the components were 0.554 - 0.890. The most frequently performed daily work of nurse managers was in the component of organising, and the most infrequently performed daily work was in the component of clinical nursing. CONCLUSIONS The study shows that the Nurse Managers' Work Content Questionnaire (NMWCQ) is suitable for measuring the current content of nurse managers' work. However, the questionnaire is new and needs additional testing such as confirmatory factor analysis with larger amounts of data.
Collapse
Affiliation(s)
- Anu Nurmeksela
- Faculty of Health Sciences, Department of Nursing Science, University of Eastern Finland, Jyväskylä, Finland
| | - Juha Kinnunen
- Central Finland Central Hospital, University of Eastern Finland, Jyväskylä, Finland
| | - Tarja Kvist
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| |
Collapse
|
10
|
Weaver SH, Hessels AJ, Paliwal M, Marx J, Hoffman K, Wurmser TA. Nurse Leaders at Night:. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.mnl.2019.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
11
|
Delineation of the Nursing Supervisor Role: A Pilot Study. J Nurs Adm 2019; 49:359-365. [PMID: 31306298 DOI: 10.1097/nna.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to describe a sample of nursing supervisors and their work. BACKGROUND The role of the nursing supervisor is not well understood. The supervisor population is poorly defined, as are their ideal academic preparation and work activities. METHODS This study followed the American Nurses Credentialing Center® framework for role delineation studies. A convenience sample of 50 nursing supervisors from New Jersey was recruited to complete an online survey including demographic data and prioritization of work activities. RESULTS Participants represented a homogeneous and aging workforce with diverse professional preparation. Exploratory factor analysis revealed 6 categories of nurse supervisor work including administrative presence, leadership liaison, patient safety and experience, patient care advocacy, throughput, and external response. Work activities were prioritized. CONCLUSIONS Nurse supervisors prioritized responding to emergencies above all other responsibilities. This study should be replicated in a nationwide sample of nurse supervisors.
Collapse
|
12
|
Peltonen LM, Siirala E, Junttila K, Lundgrén-Laine H, Vahlberg T, Löyttyniemi E, Aantaa R, Salanterä S. Information needs in day-to-day operations management in hospital units: A cross-sectional national survey. J Nurs Manag 2018; 27:233-244. [DOI: 10.1111/jonm.12700] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/13/2018] [Accepted: 07/26/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - Eriikka Siirala
- Department of Nursing Science; University of Turku and Turku University Hospital; Turku Finland
| | - Kristiina Junttila
- Department of Nursing Science; University of Turku, Finland and Group Administration, Helsinki University Central Hospital; Helsinki Finland
| | - Heljä Lundgrén-Laine
- Department of Nursing Science; University of Turku and Central Finland Health Care District; Turku Finland
| | - Tero Vahlberg
- Department of Biostatistics; University of Turku; Turku Finland
| | | | - Riku Aantaa
- University of Turku and Turku University Hospital; Turku Finland
| | - Sanna Salanterä
- Department of Nursing Science; University of Turku and Turku University Hospital; Turku Finland
| |
Collapse
|
13
|
|
14
|
Weaver SH, Lindgren TG. Getting safely through the shift: a qualitative exploration of the administrative supervisor role. J Nurs Manag 2017; 25:430-437. [DOI: 10.1111/jonm.12481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Susan H. Weaver
- Ann May Center for Nursing; Hackensack Meridian Health; Neptune USA
| | | |
Collapse
|
15
|
Weaver SH, Lindgren TG, Cadmus E, Flynn L, Thomas-Hawkins C. Report From the Night Shift: How Administrative Supervisors Achieve Nurse and Patient Safety. Nurs Adm Q 2017; 41:328-336. [PMID: 28859001 DOI: 10.1097/naq.0000000000000252] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The administrative supervisor role (the nurse leader on the evening or night shift) has been present in hospitals for more than 100 years, but research is just commencing regarding how this leader achieves nurse and patient safety. This focused ethnographic study was conducted in 2 parts. The first part consisted of focus groups with night-shift staff nurses, held at 7 hospitals in the mid-Atlantic region of the United States, with the objective of obtaining the staff nurses' perception of the supervisors' role. The second part consisted of interviews with 30 administrative supervisors, recruited nationally from 20 different states, to explore the supervisors' perspective on practices used to enhance safety. The focus group and interview transcripts were thematically analyzed, using an iterative, comparative method to identify codes and sort for patterns. The findings reveal that administrative supervisors "make it (whatever needs to be done) work" and achieve nurse and patient safety by building trust with the staff, doing rounds, educating, and providing support to the front line team. These shift leaders foster a culture of safety with their relationship-oriented leadership style. By gaining further understanding about the administrative supervisor role, new workflow processes can be explored; specific continuing education programs can be developed; and additional research can be conducted.
Collapse
Affiliation(s)
- Susan H Weaver
- Hackensack Meridian Health, Neptune, New Jersey (Dr Weaver); Center for Healthcare Quality (Drs Weaver, Cadmus, Flynn and Thomas-Hawkins), School of Nursing (Drs Lindgren, Cadmus and Thomas-Hawkins), Rutgers, The State University of New Jersey, Newark; New Jersey Collaborating Center for Nursing (Drs Weaver and Cadmus), Newark, New Jersey; and College of Nursing (Dr Flynn), University of Colorado, Aurora
| | | | | | | | | |
Collapse
|