1
|
Yasin F, Khraim F, Santos M, Forgrave D, Hamad A. Factors influencing self-care management in adult hemodialysis patients: An integrative review. Qatar Med J 2024; 2024:12. [PMID: 38654818 PMCID: PMC11037095 DOI: 10.5339/qmj.2024.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/04/2024] [Indexed: 04/26/2024] Open
Abstract
Background: End-stage renal disease (ESRD) poses a significant health challenge, with hemodialysis (HD) being the most prevalent therapy. Patients undergoing HD must comply with a strict therapeutic regimen, including dietary control, fluid restriction, and medication adherence. Successful disease management and improved outcomes rely on patients' involvement and participation in their care. Aim: To identify the factors that hinder or facilitate self-care management (SCM) in HD patients. Methodology: This review followed Whittemore and Knafl's integrative review framework. A comprehensive literature search of articles published between 2017 and 2022 was conducted in CINAHL, Medline, and PubMed using the keywords end-stage renal disease, hemodialysis, self-care management, self-care, and self-management. This search yielded 21 suitable articles for review. Results: SCM is influenced by three main factors: facilitators, barriers, and outcomes. Facilitators of SCM include self-care management interventions, patient knowledge, socio-demographic factors, family support, healthcare professionals, peer support, and psychological factors. Barriers encompass psychological and physical conditions. Outcomes include both physiological and psychological aspects. Conclusion: Understanding the factors influencing SCM in HD patients is vital for developing reliable and effective self-care strategies and interventions to enhance both physical and psychological outcomes.
Collapse
Affiliation(s)
| | - Fadi Khraim
- Faculty of Nursing, Qatar University, Doha, Qatar
| | | | | | | |
Collapse
|
2
|
Schneider AR, Ravani P, King-Shier KM, Quinn RR, MacRae JM, Love S, Oliver MJ, Hiremath S, James MT, Ortiz M, Manns BR, Elliott MJ. Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study. Can J Kidney Health Dis 2023; 10:20543581231215858. [PMID: 38033483 PMCID: PMC10685780 DOI: 10.1177/20543581231215858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Background Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making. Objective To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection. Design Qualitative descriptive study. Setting Five outpatient hemodialysis centers in Calgary, Alberta. Participants Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists). Methods We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective. Results While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers. Limitations Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study. Conclusions Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.
Collapse
Affiliation(s)
| | - Pietro Ravani
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Kathryn M. King-Shier
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Robert R. Quinn
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Shannan Love
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew T. James
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mia Ortiz
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braden R. Manns
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Meghan J. Elliott
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
3
|
Welke S, Duncanson E, Bollen C, Britton A, Donnelly F, Faull R, Kellie A, Le Leu R, Manski-Nankervis JA, McDonald S, Richards K, Whittington T, Yeoh J, Jesudason S. The impact on patients of the tertiary-primary healthcare interface in kidney failure: a qualitative study. J Nephrol 2023; 36:2023-2035. [PMID: 37632667 DOI: 10.1007/s40620-023-01742-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/19/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Clinicians and patients have reported fragmentation in the primary and tertiary healthcare interface. However, perspectives of service navigation and the impacts of fragmentation are not well defined, particularly for patients transitioning to dialysis. This study aimed to define patient perspectives of the functioning of the health service interface and impacts on healthcare experiences and engagement, informing patient-centred and outcomes-focused service models. METHODS A qualitative study was conducted through semi-structured interviews with 25 dialysis patients (16 males) aged 34-78 receiving dialysis across a multi-site tertiary service. Transcripts were analysed thematically. RESULTS Three main themes were identified: (1) The Changing Nature of General Practitioner (GP) Patient Relationships; (2) Ownership and Leadership in Kidney Care; and (3) The Importance of Nephrologist-GP Communications. Patients perceived an unreliable primary-tertiary service interface which lacked coordinated care and created challenges for primary care continuity. These impacted perceptions of healthcare provider expertise and confidence in healthcare systems. Patients subsequently increased the healthcare sought from tertiary kidney clinicians. The fractured interface led some to coordinate communication between health sectors, to support care quality, but this caused additional stress. CONCLUSIONS A fragmented primary-tertiary healthcare interface creates challenges for patient service navigation and can negatively impact patient experiences, leading to primary care disengagement, reduced confidence in health care quality and increased stress. Future studies are imperative for assessing initiatives facilitating health system integration, including communication technologies, healthcare provider training, patient empowerment, and specific outcomes in health, economic and patient experience measures, for patients transitioning to dialysis.
Collapse
Affiliation(s)
- Samantha Welke
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Emily Duncanson
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
- School of Psychology, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Chris Bollen
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Anne Britton
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Fiona Donnelly
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Randall Faull
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Andrew Kellie
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Richard Le Leu
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice, Melbourne Medical School, University of Melbourne, Parkville, VIC, Australia
| | - Stephen McDonald
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Katherine Richards
- Faculty of Health and Medical Sciences, University of Otago, Christchurch, New Zealand
| | - Tiffany Whittington
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jackie Yeoh
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| |
Collapse
|
4
|
Sousa H, Ribeiro O, Christensen AJ, Figueiredo D. Designing family-based interventions in kidney failure: The perspectives of the triad 'patients on haemodialysis/family caregivers/healthcare professionals. Br J Health Psychol 2023; 28:672-689. [PMID: 36720472 DOI: 10.1111/bjhp.12647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/14/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study explored the perspectives of people undergoing in-centre haemodialysis, family caregivers, and healthcare professionals about the development and implementation of family-based interventions in renal care settings. DESIGN A qualitative exploratory study was carried out combining purposive and snowball sampling techniques. METHODS Semi-structured interviews were submitted to thematic analysis. RESULTS A total of 82 individuals (27 adults on haemodialysis, 32 family caregivers, and 23 healthcare professionals) participated in this study. Five major themes were identified: (i) educational needs (improve disease and treatment-related knowledge; acquire better clarification on dialysis-related health behaviours); (ii) support needs (easier access to available community resources and professional psychological support; additional emotional and instrumental support from family members); (iii) expected barriers (concerns about participating in a group format; availability of the person on haemodialysis/family caregiver dyad; travel to the intervention site and associated costs); (iv) expected benefits (mutual emotional validation and support; improve family coping skills and involvement); and (v) preferences for content and format (interdisciplinary and moderated by health psychologists) and timing of the intervention (weekends and/or non-dialysis days). CONCLUSIONS Findings suggested that interventions focused on the family system in kidney failure need to follow an interdisciplinary approach, combining psychosocial support with an educational component. Future research is needed to minimize barriers to the conjoint participation of the person on haemodialysis/caregiver dyad. This study identifies important intervention goals to inform the design of family-based interventions for people receiving haemodialysis and their family caregivers.
Collapse
Affiliation(s)
- Helena Sousa
- Center for Health Technology and Services Research (CINTESIS@RISE), Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
| | - Oscar Ribeiro
- Center for Health Technology and Services Research (CINTESIS@RISE), Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
| | - Alan J Christensen
- Department of Psychology, East Carolina University, Greenville, North Carolina, USA
| | - Daniela Figueiredo
- Center for Health Technology and Services Research (CINTESIS@RISE), School of Health Sciences, University of Aveiro, Aveiro, Portugal
| |
Collapse
|
5
|
Baragar B, Schick-Makaroff K, Manns B, Love S, Donald M, Santana M, Corradetti B, Finlay J, Johnson JA, Walsh M, Elliott MJ. "You need a team": perspectives on interdisciplinary symptom management using patient-reported outcome measures in hemodialysis care-a qualitative study. J Patient Rep Outcomes 2023; 7:3. [PMID: 36662325 PMCID: PMC9859959 DOI: 10.1186/s41687-022-00538-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/26/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are standardized instruments used for assessing patients' perspectives on their health status at a point in time, including their health-related quality of life, symptoms, functionality, and physical, mental, and social wellbeing. For people with kidney failure receiving hemodialysis, addressing high symptom burden and complexity relies on care team members integrating their expertise to achieve common management goals. In the context of a program-wide initiative integrating PROMs into routine hemodialysis care, we aimed to explore patients' and clinicians' perspectives on the role of PROMs in supporting interdisciplinary symptom management. METHODS We employed a qualitative descriptive approach using semi-structured interviews and observations. Eligible participants included adult patients receiving intermittent, outpatient hemodialysis for > 3 months, their informal caregivers, and hemodialysis clinicians (i.e., nurses, nephrologists, and allied health professionals) in Southern Alberta, Canada. Guided by thematic analysis, team members coded transcripts in duplicate and developed themes iteratively through review, refinement, and discussion. RESULTS Thirty-three clinicians (22 nurses, 6 nephrologists, 5 allied health professionals), 20 patients, and one caregiver participated in this study. Clinicians described using PROMs to coordinate care across provider types using the resources available in their units, whereas patients tended to focus on the perceived impact of this concerted care on symptom trajectory and care experience. We identified 3 overarching themes with subthemes related to the role of PROMs in interdisciplinary symptom management in this setting: (1) Integrating care for interrelated symptoms ("You need a team", conducive setting, role clarity and collaboration); (2) Streamlining information sharing and access (symptom data repository, common language for coordinated care); (3) Reshaping expectations (expectations for follow-up, managing symptom persistence). CONCLUSIONS We found that use of PROMs in routine hemodialysis care highlighted symptom interrelatedness and complexity and helped to streamline involvement of the interdisciplinary care team. Issues such as role flexibility and resource constraints may influence sustainability of routine PROM use in the outpatient hemodialysis setting.
Collapse
Affiliation(s)
- Brigitte Baragar
- grid.22072.350000 0004 1936 7697Department of Medicine, Cumming School of Medicine, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
| | - Kara Schick-Makaroff
- grid.17089.370000 0001 2190 316XFaculty of Nursing, University of Alberta, Edmonton, AB Canada
| | - Braden Manns
- grid.22072.350000 0004 1936 7697Department of Medicine, Cumming School of Medicine, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute of Public Health, University of Calgary, Calgary, AB Canada
| | - Shannan Love
- grid.22072.350000 0004 1936 7697Department of Medicine, Cumming School of Medicine, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
| | - Maoliosa Donald
- grid.22072.350000 0004 1936 7697Department of Medicine, Cumming School of Medicine, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Maria Santana
- grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute of Public Health, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Pediatrics, University of Calgary, Calgary, AB Canada
| | - Bonnie Corradetti
- grid.413574.00000 0001 0693 8815Medicine Strategic Clinical Network, Kidney Health Section, Alberta Health Services, Edmonton, AB Canada
| | - Juli Finlay
- grid.22072.350000 0004 1936 7697Department of Medicine, Cumming School of Medicine, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
| | - Jeffrey A. Johnson
- grid.17089.370000 0001 2190 316XSchool of Public Health, University of Alberta, Edmonton, AB Canada
| | - Michael Walsh
- grid.25073.330000 0004 1936 8227Department of Medicine, McMaster University, Hamilton, Canada ,grid.25073.330000 0004 1936 8227Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada ,grid.413615.40000 0004 0408 1354Population Health Research Institute, Hamilton Health Sciences / McMaster University, Hamilton, Canada
| | - Meghan J. Elliott
- grid.22072.350000 0004 1936 7697Department of Medicine, Cumming School of Medicine, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute of Public Health, University of Calgary, Calgary, AB Canada
| |
Collapse
|
6
|
Ibelo U, Green T, Thomas B, Reilly S, King-Shier K. Ethnic Differences in Health Literacy, Self-Efficacy, and Self-Management in Patients Treated With Maintenance Hemodialysis. Can J Kidney Health Dis 2022; 9:20543581221086685. [PMID: 35356537 PMCID: PMC8958521 DOI: 10.1177/20543581221086685] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background: There is a gap in research investigating the potential impact of ethnicity on health literacy, self-efficacy, and self-management in patients treated with maintenance hemodialysis (MHD). Objective: To explore (1) the associations between health literacy, self-efficacy, and self-management among outpatients with kidney failure receiving treatment with MHD, and (2) the differences in health literacy and self-efficacy based on characteristics of ethnicity (ie, physical resemblance and proficiency in the language of the host population), known to be associated with health care access and health outcomes. Design: Cross-sectional Setting: Outpatients receiving MHD at 7 adult hemodialysis centers in Calgary, Alberta from September 2014 to December 2014. Patients: Participants were grouped into 2 groups based on a proposed 4-quadrant framework of a multicultural society. Quadrant 1 comprised outpatients with physical resemblance and first language of the host population (ie, white and English as a first language), whereas quadrant 4 participants comprised outpatients with physical resemblance and first language not of the host population (ie, non-white and first language other than English). A total of 78 patients (nQ1 = 44, nQ4 = 34) were included. Measurements: Heath literacy, self-efficacy, and self-management were measured using the Health Literacy Questionnaire (HLQ), Strategies Used by People to Promote Health (SUPPH), and Patient Activation Measure-13 (PAM-13), respectively. Methods: Convenience sampling was used to recruit participants at each of the 7 adult hemodialysis centers. All participants completed a study package, which included a demographic questionnaire, HLQ, SUPPH, and PAM-13. Spearman rho was calculated to identify correlations between patient activation level and HLQ and SUPPH scores. Independent t tests were performed to identify differences in HLQ and SUPPH scores between Q1 and Q4 participants. Stepwise regression was performed in other analyses to identify predictor variables of patient activation level. Results: Statistically significant correlations were identified between patient activation level and the health literacy domains of “ability to actively engage with health care providers” (rHLQ6= .535, P < .001), “ability to find good health information” (rHLQ8 = .611, P < .001), and “understanding health information well enough to know what to do” (rHLQ9 = .712, P < .001). There was a statistically significant difference between Q1 and Q4 participants in the health literacy domain of “ability to find good health information” (P = .048). “Understanding health information well enough to know what to do” and “actively managing health” were included in the final stepwise regression model, F(2, 72) = 32.232, P < .001. Limitations: The cross-sectional design limits the generalizability of the results. The small sample size limits the power to identify significant associations and differences. Although English was not the first language of Q4 participants, all were proficient in English, meaning potential differences of a key subgroup of Q4 (ie, those who did not speak any English) were not captured. Conclusion: The HLQ allowed for the creation of a health literacy profile of patients with end-stage kidney disease receiving treatment with MHD. The findings suggest possible associations between specific domains of health literacy and patient activation. Outpatients’ representative of Q4 receiving treatment with MHD appear to struggle more with finding good health information, which may leave them at a disadvantage in the early phases of their self-management efforts. The findings highlight potential opportunities to better tailor patient care to support patients in their self-management, particularly for patients from ethnic minority backgrounds.
Collapse
Affiliation(s)
| | - Theresa Green
- School of Nursing Midwifery and Social Work, The University of Queensland, Brisbane Saint Lucia, Australia
- Faculty of Nursing, University of Calgary, AB, Canada
| | - Bejoy Thomas
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Sandra Reilly
- Faculty of Nursing, University of Calgary, AB, Canada
| | | |
Collapse
|