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It’s 2016 and APRNs are still not recognized in all of the United States.  

In 2010, the Institute of Medicine released the report, The Future of Nursing, which outlined the need for advanced practice nurses (APRNs) to gain full practice authority in the United States.  This document, a collaboration of the Committee on the Robert Wood Johnson Initiative, set the policy agenda for APRNs to be given full practice authority in the majority of states that did not already have the legislation to support that practice. Full practice authority in every state is necessary to provide consistency in APRN practice, to provide access to healthcare for patients in greater numbers, to reduce healthcare costs and improve preventative health practices.  The IOM points out the disparities and waste in our current system, such as the ability of an APRN to have full practice authority in one state and go to a neighboring state and be unable to prescribe as much as a Tylenol without a physician’s oversight.  The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education set forth the structure in which states could base legislation of APRNs in the hopes to standardize practice.

 

The goal was to implement the model by 2015.Stethoscope-2

As of 2016, twelve states have fully implemented the full Consensus Model through legislation.  Many are close, but some are far from reaching full practice authority for APRNs.  I moved from Oregon, which has full practice authority, to Texas which limits APRN practice and requires burdensome physician oversight.  Instead of serving patients in my rural community, which suffers from disparities in healthcare services, I work in a nursing leader position, with a BSN requirement.   I am working with the state APRNs to advance legislation that will remove barriers to practice, but there is a lot of opposition from another special interest group, physicians.  Some physicians view APRNs as competitors, instead of partners in expanding healthcare services.

Political victories are happening.

West Virginia is on the cusp of expanding APRN practice authority and are waiting for their governor to sign the bill into legislation. Amy Summers, a member of the West Virginia legislature, was the lead sponsor of HB 4334 which expanded APRN authority to practice independently and to expand prescriptive authority.

Summers stated in defense of the bill, “This is not a new idea, this isn’t something that needs studied further. Iowa has allowed full practice authority for 33 years, Alaska 28 years, New Mexico 20 years.  No state has ever repealed full practice authority once it was given.”

I hope that Texas, and the many states that have yet to adopt the Consensus Model, will move towards joining forward thinking states.  States like Oregon, Idaho, Iowa, Utah, Montana, Maine, Nevada, New Mexico, North Dakota, Vermont, Colorado and Hawaii, all of which have given full practice authority to all APRNs.

How does your state measure up? Click here to find out!

 

 

 

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Why Mid-Level is a Dirty Word

A colleague of mine recently described herself as a “mid-level provider.”thumbs-down1

I cringed.

There is nothing mid-level about her.  She has spent over six years in a university and hundreds of clinical hours learning to become a Nurse Practitioner, not half of a physician.  She spent years as a bedside nurse prior to advancing her education to become a NP.  Physicians and nurses have two separate career paths in which they collaborate to care for men, women, and children.

When I first heard the term “midlevel” I wondered if the Advanced Practice Nurse (APRN) is in the middle, who is above and below?  If APRNs are viewed as below physicians, does that make her above registered nurses?  An APRN has advanced assessment skill and practice authority, but she is still a nurse.  She always maintains her registered nurse license.  An APRN does not graduate from or stop being a nurse when she becomes an advanced practice nurse!

Words mean things. Why would anyone want to go see someone for their healthcare needs that is described as “mid-level?”  APRNs produce the same good outcomes as other primary care providers.  Their outcomes are not mid-level, their care is not mid-level, and their experience is not mid-level.

The use of “mid-level” comes from the U.S. government.  They use the terms mid-level and non-physician practitioner to describe APRNS and Physicians Assistants (PA).  The APRN Consensus Model encourages the use of the term Advanced Practice Nurse (APRN) to describe Nurse Midwives, Clinical Nurse Specialists, Nurse Anesthetists, and Nurse Practitioners.    With the implementation of the APRN Consensus Model, throughout the majority of the United States, the use of APRN is increasing. It is being used more in legislative language too.  Despit this progress, the use of “mid-level” is still rampant. We need to encourage the use of APRN in our professional circles.

 

 

Standing together, as healthcare professionals, we can promote the good work of APRNs by using an accurate descriptor.  Our patients are listening.

 

 

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Joy Who?

The internet was in an uproar. Miss Colorado, Kelley Johnson, delivered a monologue about her experience of being “just a nurse” for the talent portion of the Miss America pageant. I watched it on YouTube the night of the contest. Like many nurses, I felt all the warm, fuzzy, nurse feelings and even got a little misty eyed. By Tuesday morning, the news reached my Facebook nursing groups. Joy Behar and Michelle Collins had mocked Miss Colorado on The View. Ms. Collins thought it would be a good laugh to poke fun at the heartfelt monologue delivered by Nurse Kelley. Ms Behar chimed in with the question, “why does she have a doctor’s stethoscope around her neck?”

A doctor’s stethoscope! Behar poked a sleeping bear with those words. Nurses roared into action as the disparaging remarks reached nurses across the globe. Hashtags like #nursesshareyourstethoscopes, #nursesrock, #nursesmatter, #notacostume, #mytalentisnursing, #nursesunite and #notjustanurse began trending on social media. I wish that Ms. Behar and Ms. Collins had supported Nurse Kelley, not only as a healthcare professional, but as a woman. It was disturbing to watch an all-woman-panel mock another woman for sharing her talent, the art of nursing.

The backlash from three million nurses was swift and strong. Pictures of nurses wearing stethoscopes flooded my news feeds. I spent time retweeting every one of my fellow nurses posts about the scandal. I was caught up in the collective outrage and for a few days I felt united with my sister and brother nurses.

Weeks later, the nurse hashtags have stopped trending and the conversation has changed to other hot topics. All of the nurse empowerment energy has evaporated.

Have we once again become stethescope#justnurses?

Joy Behar’s comment was careless. It was a throw away thing to say to fill up space and to seem like she had something intelligent to add to the conversation. I don’t believe that she meant it maliciously, she was being thoughtless. Her thoughtlessness united nurses in a way that I have not seen since nurses jumped on planes and busses to help in the aftermath of Hurricane Katrina. The energy on social media was exciting. It was gratifying to read supportive comments and see nurses being given positive attention. I loved seeing all the stethoscopes and reading nursing stories about where those stethoscopes have been. For a few days it has felt like nurses were united and a part of a large community. United in their outrage of being publicly mocked.
It is now clear that nurses have the ability to direct national conversations. Where have all the hashtags gone? Why aren’t there trending hashtags like #endhealthdisparity, #decreasepatientratios, #stoplateralviolence, #nurseautonomy, or #APRNsIncreaseAccessToHealthcare? Healthcare policy and laws are influenced by a handful of lobbyists and legislators. These lobbyists and legislators number far fewer than three million nurses, but their decisions affect the entire nation. Can you envision a healthcare system being directed by our modern day Florence Nightingales and Clara Bartons, with the support of the national nursing community?
The best thing that could result from this stethoscope spectacle would be for nurses to finally find their voice.

We have power to influence, educate and advocate for the healthcare changes that we know we need. We can command a national stage whenever we choose to unite behind a cause. Its time to come together to influence issues that affect our friends, neighbors and families. Nurses are never just nurses, it is time to prove it.

To take action start here: American Nurses Association

 

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Giving Thanks for Advanced Practice Nurses


     I am thankful for advanced practice nurses (APRN) A Nurse Practitioner (NP) is one type of advanced practice nurse and one that probably comes most readily to the mind of the public. Certified Nurse Midwives (CNM), Certified Nurses Anesthetists (CRNA), and Clinical Nurse Specialists (CNS) are also APRNs and fill similar, but diverse roles. I have been fortunate to have been cared for and mentored by many APRNs throughout my life and career. T
his November I wanted to share how APRNs have touched my life and express my gratitude.

1.As a young child, my family accessed healthcare through the county public health system. Thanks to public health nurses, and the APRNs that led them, I was vaccinated against diseases and screened for health problems. I grew up healthy despite my parents’ lack of healthcare insurance and money.

2. As a teenager, living in a rural community, my primary healthcare provider was a Nurse Practitioner. She practiced in a small healthcare clinic a few minutes from my house. At that time I was covered by insurance, but she had low rates for self-pay patients. I loved the way that she took time to listen to my teenage complaints and helped me navigate my own health for the first time.

3. Then next time I came across an APRN I was a service member’s wife, struggling to raise a growing family during wartime. A Nurse Practitioner screened me for depression and referred me to a support group. That support group helped me to survive and thrive through each of my husband’s deployments.

4. In nursing school a Nurse Practitioner faculty member candidly shared the practice struggles facing APRNs. She mayNurse-Heart have thought she was dissuading me from entering the struggle, but she inspired me to eventually join the cause.

5. I learned about the true mission of public health at the side of a CNM. Her job was to make prenatal and postpartum home visits. She taught me how to meet people wherever they are in life. I can still picture her on a dozen different sofas, rattling off nursing advice in both Spanish and English.

6. My leadership preceptor in nursing school was also a CNM. She was the director at a community hospital labor and delivery department. She ran around that unit with a mug of tea she would intermittently reheat, but never finish. She taught me what is meant to be a visible leader.

7. When my career turned from adult medicine to perinatal nursing, I learned how to be fully present and care for a woman in labor thanks to a group of CNMs. They taught me how to seamlessly involve the partner and other present family members. I can’t express how much of the nurse I am today is directly due to the hours I spent in the sacred spaces that those women created for our patients.

8. When I decided to become an APRN, I was mentored by two amazing CNSs and a wonderful NP. The lessons they taught went far beyond how to dictate a note or prescribe a medication. I am truly grateful for their time and advice. I owe them much of my career success. The greatest gift they gave me was belief in my own ability. They drilled in me to not sell myself short, to not settle and to unabashedly pursue my goals as an equal player in the healthcare arena.

9. The darkest year of my life was attended by another APRN. A CNM helped me through back-to-back perinatal losses. She was the first primary care provider to truly listen to my health complaints and she diagnosed me with hypothyroidism. The diagnosis came too late to affect my pregnancy, but she helped me on the road to health, both physically and mentally.

10. I don’t want to leave out CRNAs! I work with brilliant, funny and energetic CRNAs. They are an important part of the perinatal team. I am thankful that when we are running to the same emergency together, I know our patient can be in the OR within minutes receiving lifesaving care from our team.

      I would not be the person I am today without APRNs. It’s possible I may not even be here without some of them. APRNs fill an increasingly important role in our healthcare system. Despite the amazing, holistic and safe care that APRNs provide patients, they experience many barriers to practice. Our nation continues to face a crisis in healthcare that could be greatly reduced by allowing all APRNs to practice to their full scope, in every state. Currently APRNs are lobbying for independent practice in many states and nationally. Independent practice is evidence based and a safe policy. We need public support to help pass legislation to allow more APRNs to care for patients. To learn more about the APRN regulations in your state and pending legislation click here. If you are grateful for an APRN, please share your story in the comments.

This post was written as part of the Nurse Blog Carnival. More posts on this topic can be found at http://yourahi.org/blog.

If you are interested in participating find out more details and sign up.

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10 ways to be your boss’s favorite employee. -Even if they never say it out loud.

1. Be positive.

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Being a leader involves a lot of problem solving. Much of your boss’s day is spent thinking about processes that are broken, employee complaints and negative issues. The positive employees stand out and are greatly appreciated.

2. Have a sense of humor.

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Sometimes the only solution in a terrible situation is to laugh. Laughing at the boss’s jokes is highly encouraged. Being able to keep a sense of humor, especially about yourself, is a refreshing quality in an employee.

3. Don’t just volunteer, follow through!

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What ever you have raised your hand to volunteer for will become your boss’s job if you don’t follow through. Volunteering in meetings is only the first step.

4. Make their job easier.

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It may seem like your boss is getting credit for your hard work. Really they are getting credit for having a exemplary employee. If you can take something off their plate, do it.

5. Meet deadlines and bring solutions.

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Feedback and reporting company issues is important, but bring a possible solution when you knock on the office door. Meeting deadlines or at least keeping your boss in the loop of your progress is vital. After you were assigned a task, she is counting on you to cross the finish line.

6. Be honest. Leaders need constructive critiquing too.

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Yes, laughing at the boss’s jokes is good, but being a yes-man is not helpful. Be honest, in a kind way, to help your boss recognize areas that need improvement.

7. Give trust.

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Don’t automatically assume that every decision or action your boss makes is a direct attempt to ruin your life.

8. Say thank you.

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Just as much as you like to feel appreciated, your boss needs it too. He probably can’t remember the last time an employee thanked him. If the thought of your boss quitting makes you feel ill, let them know how much you appreciate them now. Leaders usually do not hear the positive impacts they made on employees until their going away party. Too little. Too late.

9. Tell them what you need.

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Leaders want you to be successful, but are not mind readers. Tell them what you need. It may not be possible to immediately get your needs filled, but knowing is half the battle.

10. Let them have a bad day.

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Everyone has the occasional bad day. Your leader is human and is going to disappoint you and themselves at some point. Don’t judge them too harshly for one bad shift. Grab the tissues and chocolate and let them know that tomorrow is a new day.

 

 

 

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The Little Blue Button

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A “code” is the term that medical professionals use to describe the orchestrated chaos that surrounds a patient that is on the brink of death.  Depending on the facility a code may be called a Code Blue, Code Red, Code CPR, or sometimes Code 99.  They all mean the same thing.  A person is about to die unless there are medical interventions made immediately.  Sometimes it means that death will come no matter how hard we try to stop it.

 

A few months past graduation I experienced my first code on my own patient.  The man had been verbally abusing me all day.  I had been running around trying to make him happy and also care for my other five patients.  He was bellowing from his bed that he was going to die.  A lot of patients speak in that way, but something about the way he said it terrified me a little.  All his vitals, physical assessment findings and that he was able to yell with so much energy all assured me that he was stable.  I called the physician anyway.  He agreed to assess the patient. I went to check on my suddenly quiet patient.  When I walked into the room I knew something was different.  I will never forget how grey he looked.  I froze in a moment that felt like eternity while I listened and looked for breathing.  It only took a few seconds to confirm.  I reached up above his head and pressed the small blue button.

 

I was the person yelling now.

 

I called above the alarm sound for help. Help came.  Almost before I could lay the patient flat in the bed, a nursing aid, with a football player build, began chest compressions.  Respiratory commanded the head of the bed, bagging and preparing for intubation. A metal crash cart clanked into existence, pushed by my charge nurse.  The emergency room physician and intensive care nurse rushed in together. The ICU nurse asked who the primary nurse was.  All I could think was ‘Oh Crap! That’s me.’  She told me to grab the chart (that’s back when patient’s records were big, clunky, 2-ringed, plastic folders stuffed with a ream of paper printouts and handwritten notes) and call the patient’s physician.

 

I ran to the desk and called the doctor again. He was just getting off the elevator. We met at the patient’s bedside. I calmly answered questions about history, vitals, and labs, all while the resuscitation dance continued.  I was calm only on the outside.  Inside my mind raced, searching for what I might have missed.  This man had been screaming at me all shift.  How could we be coding him now?  I couldn’t think of anything I could have or would have changed.  Even now looking back, with much more experience, I know gave him appropriate care.  I watched the code continue, clutching the hard plastic chart.  I optimistically observed that his color was pink again.  Surely that was a good sign, I told myself.

 

As if someone had flipped a switch, everything stopped.

 

The ER physician called time of death after nearly 40 minutes of trying to coax my patient back to life.  I watched as my patient lost his rosy color while the team waded through the open package wrappers that had been hastily discarded on the floor.  The CNA stayed and helped me to clear the debris and prepare my patient for the morgue.  The aftermath of the code was over quickly.  I think that is what stunned me the most.  The physicians and nurses went on caring for their patients.  Housekeeping came and cleaned the room for my next admission.  I did not have time to cry or sit in disbelief or process what had happened.

 

The shift went on and so did I.

 

I have since been to countless codes.  Sometimes I am doing the compressions.  Sometimes I am the nurse directing the chaos.  Occasionally I am the primary nurse questioning every action I did or didn’t make that shift. Luckily one aspect of patient codes has changed since I was a new nurse.  It is now an expectation in many hospitals that a debrief occurs after a code, regardless of the outcome.

 

A debrief is conducted as soon as possible after the event.  All available team members are expected to attend.  It is a confidential and non-discoverable group discussion of the event.  The purpose is to discuss the facts, problems, barriers, needed improvements and to acknowledge and share feelings.  This is not a time to place blame or try to find fault with one another. This opportunity to discuss the event and acknowledge how we feel about it is a valuable practice.  I never want to feel that losing a patient is business as usual.

 

Debriefing is the pause that we need to take to acknowledge, gain knowledge and make adjustments for the next time we press that little blue button.

 

 


Debriefing Steps 

1. Introduction: The facilitator establishes the group goals and rules and reinforces the need for confidentiality about anything that transpires within the group.

2. Fact gathering: Each staff person describes what happened and facts are gathered.

3. Reaction phase: Led by the facilitator, the group examines its feelings, thoughts, and responses to the event experienced. If the debriefing session happens soon after the event occurred, there might not be any symptoms.

4. Symptom phase: If some time has elapsed since the event, group members may be experiencing symptoms. The facilitator helps the group examine how these reactions have affected personal and work lives.

5. Stress response: The facilitator teaches group members about their stress response.

6. Suggestions: The facilitator offers guidance on how to cope with stress related to the incident.

7. Incident phase: Group members identify positive aspects of the event.

8. Referral phase: The facilitator concludes with this phase, whereby specific individuals who require additional support are referred for individual follow-up.     

Adapted from: Hanna, D., & Romana, M. (2007). Debriefing After A Crisis. Nursing Management (Springhouse), 38-42,44–45,47.


This post was written as part of the Nurse Blog Carnival.

More posts on this topic can be found at http://scrub-ed.com/

If you are interested in participating find out more details and sign up.

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*all accounts are fictional
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Book Review: Your Next Shift by Elizabeth Scala

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Fellow Nursepreneur, Elizabeth Scala, has captured the nursing spirit again with her second book, Your Next Shift.  This is a great read for any nurse, wether you have found your career bliss or are still searching.   

Elizabeth Scala shares her own savvy advice while managing to tie in philosophies from great thinkers from Churchill to Green Day.  Scala gives us a sneak peek into her personal reflections in which we easily can recognize our own struggles and fears.

“When you are OK with where you are currently at, you are able to celebrate everything about you and then exude that energy out into the world.” Elizabeth Scala

Your Next Shift is not a blueprint for becoming someone else. Scala guides her fellow nurses through a journey of self awareness while sharing her steps to success, however you define it.

I recommend this book for every nurse that feels that there must be more to nursing, happy nurses that want to level-up their careers, and nurses that feel the call of a slightly different path.

-Carrie Sue Halsey

 

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Nurse burnout: When passion isn’t enough

A few months ago I was asked by the editor of Sigma Theta Tau’s online magazine, Reflections on Nursing Leadership, to write an article about nurse burnout. They published it as a part of their Nurses Week line up. In the article I share my personal struggle with nurse burnout and how I overcame it. I am very pleased to have my writing published in Reflection on Nursing Leadership.

Please take a few minutes to read and share with your nurse friends.  Chances are you have felt burned out in your career.  Share in comments how you renewed your passion for nursing.

 

 

 

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13 Fundamentals for Practicing Nursing

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National Nurses Week is a time set aside for the public to recognize the amazing work of nurses.  Nurses will be the topic and focus of hospitals, newspapers and media outlets.  Our accomplishments, character and hard work will be applauded and we will receive all kinds of tokens of appreciation from employers, patients and family.

This year instead of another pen, coffee mug or tote bag, I want to give nurses something that that won’t end up in the summer yard sale.

 

Rosemarie Rizzo Parse’s 13 Fundamentals for Practicing Nursing

 

  • Know and use nursing frameworks and theories.

You can begin with Parse’s theory of Humanbecoming, which is an insightful nursing theory that describes how nurses and patients co-create the health experience.  Parse marries the art and science of nursing in a beautiful and applicable way.

 

  • Be available to others.

Nurses are busy.  Do not let the fast pace of healthcare prevent you from being available.  Remember to be available for the nurses around you. No one understands you quite like a fellow nurse. Take the time to listen, help and care for one another.

 

It is a poor coping mechanism to view patients as diseases, room numbers or annoyances.  Nursing is stressful, people are not always kind, and you may never hear a thank you, but it is important to value everyone as a human presence.

 

  • Respect differences in view.

Whether you are a new graduate or about to retire, you are a nurse with opinions.  Differences in opinions are good!  Respecting differences of view is important too.  Creating a safe and welcoming environment, for everyone to share their view, will allow nursing knowledge to evolve and grow.

 

  • Own what you believe and be accountable for your actions.

If you believe in something or someone, stand up and speak up.  If you turn out to be wrong, admit it and move on.

 

  • Move on to the new and untested.

Change is hard.  No one likes it, but change is necessary and good for us and nursing.  If we did not push forward and try new nursing interventions we would still be sterilizing our own needles and fetching coffee for physicians. Parse’s theory is a paradigm shift away from medical thinking that embraces nursing as a standalone science.

 

  • Connect with others.

Compassion, caring, respect, understanding are all qualities that nurses help nurses to connect with the healthcare team, including the patients.

 

  • Take pride in self.

You are not “just a nurse.” Being a nurse is exceptional.  Don’t shortchange your contributions to healthcare.  You are brilliant, own it!

 

  • Like what you do.

If you hate your job, find one where you can be happy.  There are endless opportunities in nursing.  You owe it to yourself and your patients to like coming to work every day.

 

  • Recognize the moments of joy in the struggles of living.

Life is hard.  Take time to recognize and feel joy when you find it.

 

  • Appreciate mystery and be open to new discoveries.

Nursing is a beautiful work. We are the companions to humanity throughout the life span and in every imaginable condition. We continue to discover what it means to be human day after day.  Be open to the mysteries of life and embrace what you find.

 

  • Be competent in your chosen area.

            What have you been doing since you graduated nursing school?  Have you been to a conference, read a journal, taken a class?  Choose your nursing niche and keep learning.

 

Taking time for self is vital in order to prevent compassion fatigue and nurse burnout.  Nurses are known for putting themselves last.  Their own health, spirituality, emotion and mental needs are often put aside in order to care for others.  Take care of yourself!  Take a few minutes to meditate, pray or sit quietly during a hectic shift and you will feel the difference, and so will your patients.

 

Thank you to all my nursing colleagues around the world!  This is the week that everyone remembers that nurses are a special kind of awesome. 

Let’s remember this about ourselves the other fifty-one weeks of the year!

 

 

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Bournes, D., & Mitchell, G. (2014). Humanbecoming. In Nursing Theorists and Their Work(8th ed., pp. 464-495). St. Louis: Elsevier Mosby.

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