Denise Bryant-Lukosius

McMaster University, Hamilton, Ontario, Canada

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Publications (39)21.06 Total impact

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    ABSTRACT: Clinical nurse specialists (CNSs) are major providers of transitional care. This paper describes a systematic review of randomized controlled trials (RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional care. We searched 10 electronic databases, 1980 to July 2013, and hand-searched reference lists and key journals for RCTs that evaluated health system outcomes of CNS transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality of Health Economic Studies tools. The quality of evidence for individual outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. We pooled data for similar outcomes. Thirteen RCTs of CNS transitional care were identified (n = 2463 participants). The studies had low (n = 3), moderate (n = 8) and high (n = 2) risk of bias and weak economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mortality. For patients with heart failure, CNS care delayed time to and reduced death or re-hospitalization, improved treatment adherence and patient satisfaction, and reduced costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care improved caregiver depression and reduced re-hospitalization, re-hospitalization length of stay and costs. For high-risk pregnant women and very low birthweight infants, CNS care improved infant immunization rates and maternal satisfaction with care and reduced maternal and infant length of hospital stay and costs. There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed. © 2015 John Wiley & Sons, Ltd.
    Journal of Evaluation in Clinical Practice 07/2015; DOI:10.1111/jep.12401 · 1.58 Impact Factor
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    ABSTRACT: To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care. A systematic review of randomised controlled trials reported since 1980. 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites. Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes. 11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: -€6.41; 95% CI -€9.28 to -€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly. Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    BMJ Open 06/2015; 5(6):e007167. DOI:10.1136/bmjopen-2014-007167 · 2.06 Impact Factor
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    ABSTRACT: The transfer of health-related research knowledge between producers and users is a complex, dynamic and iterative process. There has been little research describing the preferred knowledge transfer strategies used by different stakeholder groups, including healthcare providers, policymakers and administrators. The purpose of the survey was to gain an understanding of the content and preferred dissemination strategies of knowledge users of briefing notes about the effectiveness of advanced practice nursing (APN) roles in Canada. An on-line cross-sectional survey was conducted from December 2011 to January 2012. Purposeful sampling was used to identify the target audience. The questionnaire included six items. The response rate was 44% (n=75/170). Participants identified that the briefing note should concisely summarize definitions for APN roles and information about the safety, effectiveness, cost savings and effective role implementation strategies. Multiple approaches were favoured to disseminate the information. Preferred dissemination strategies included personalized emails, meeting with briefing note recipients, engaging nurse practitioners and clinical nurse specialists in organizations where APN roles have been successfully implemented, engaging the media and using social media. The use of briefing notes has shown promise. More research is needed to evaluate the effectiveness of tailored briefing notes. Copyright © 2015 Longwoods Publishing.
    Nursing leadership (Toronto, Ont.) 03/2015; 28(1):11-23. DOI:10.12927/cjnl.2015.24236
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    ABSTRACT: Objectives To determine the cost-effectiveness of nurse practitioners delivering transitional care. Design Systematic review of randomised controlled trials. Data sources Ten electronic databases, bibliographies, hand-searches, study authors, and websites. Review methods We included randomised controlled trials that compared formally trained nurse practitioners to usual care and measured health system outcomes. Two reviewers independently screened articles and assessed study quality using the Cochrane Risk of Bias and the Quality of Health Economic Studies tools. We pooled data for similar outcomes and applied the Grading of Recommendations Assessment, Development and Evaluation tool to rate the quality of evidence for each outcome. Results Five trials met the inclusion criteria. One evaluated one alternative provider nurse practitioner (154 patients) and four evaluated six complementary provider nurse practitioners (1017 patients). Two were at low and three at high risk of bias and all had weak economic analyses. The alternative provider nurse practitioner had similar patient outcomes and resource use to the physician (low quality). Complementary provider nurse practitioners scored similarly to the control group in patient outcomes except for anxiety in rehabilitation patients (MD: -15.7, 95%CI: -20.73 to -10.67, p < 0.001) (very low quality) and patient satisfaction after an abdominal hysterectomy (MD: 14, 95%CI: 3.5 to 24.5, p < 0.01) (low quality), both favouring nurse practitioner care. Meta-analyses of index re-hospitalisation up to 42 days (n = 766, pooled relative risk (RR): 0.69, 95%CI: 0.34 to 1.43, I2 = 0%) and any re-hospitalisation up to 180 days (n = 800, pooled RR: 0.87, 95%CI: 0.69 to 1.09, I2 = 32%) were inconclusive (low quality). Complementary provider nurse practitioners significantly reduced index re-hospitalisation over 90 days (RR: 0.55, 95%CI: 0.32 to 0.94, p = 0.03) and 180 days (RR: 0.62, 95%CI: 0.40 to 0.95, p = 0.03) in complex care patients (both low quality) and they significantly reduced the number and duration of rehabilitation patient-to-staff consultation calls (p < 0.05). Conclusions Given the low quality evidence, weak economic analyses, small sample sizes, and small number of nurse practitioners evaluated in each study, evidence of the cost-effectiveness of nurse practitioner-transitional care is inconclusive and further research is needed.
    International journal of nursing studies 01/2015; 52(1):436. DOI:10.1016/j.ijnurstu.2014.07.011 · 2.25 Impact Factor
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    ABSTRACT: Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (), NP-transition (), NP-inpatient (), CNS-outpatient (), CNS-transition (), and CNS-inpatient (). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
    09/2014; DOI:10.1155/2014/896587
  • Nancy Carter · Denise Bryant-Lukosius · Alba DiCenso · Jennifer Blythe · Alan J Neville
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    ABSTRACT: Triangulation refers to the use of multiple methods or data sources in qualitative research to develop a comprehensive understanding of phenomena (Patton, 1999). Triangulation also has been viewed as a qualitative research strategy to test validity through the convergence of information from different sources. Denzin (1978) and Patton (1999) identified four types of triangulation: (a) method triangulation, (b) investigator triangulation, (c) theory triangulation, and (d) data source triangulation. The current article will present the four types of triangulation followed by a discussion of the use of focus groups (FGs) and in-depth individual (IDI) interviews as an example of data source triangulation in qualitative inquiry.
    Oncology Nursing Forum 09/2014; 41(5):545-547. DOI:10.1188/14.ONF.545-547 · 1.91 Impact Factor
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    ABSTRACT: Purpose/Objectives: To examine healthcare providers' (HCPs') perceptions of the supportive care needs of men with advanced prostate cancer (APC). Research Approach: A qualitative, descriptive study. Setting: Healthcare facilities caring for men with APC in a south-central region of Ontario. Participants: 19 nurses, physicians, and allied health providers who cared for men with APC in outpatient settings. Methodologic Approach: Interviews and focus groups. Findings: HCPs identified four themes related to men's supportive care needs: pain and symptom management, informational needs, emotional needs, and the need for practical assistance. HCPs emphasized issues related to pain, urinary incontinence, and fatigue. They also reported that men continually ask for more information related to treatment, side effects, and prognosis. Participants identified a variety of barriers in meeting supportive care needs, including lack of management strategies, poor knowledge retention, and the "stoic and old-school" nature of men in this population. Conclusions: Supportive care for this population can be improved through more focused implementation of interprofessional care, with clearly defined professional roles and additional specialized roles to address prostate cancer pain, urinary incontinence, and fatigue. Interpretation: Specialized roles in the management of pain, urinary incontinence, and fatigue affecting men with APC could be integrated into interprofessional care to meet supportive care needs.
    Oncology Nursing Forum 07/2014; 41(4):421-30. DOI:10.1188/14.ONF.421-430 · 1.91 Impact Factor
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    ABSTRACT: Clinical nurse specialists (CNSs) are advanced practice nurses. They contribute to the quality and safety of patient care by providing an advanced level of clinical care to patients and families and by supporting healthcare team members to deliver evidence-based care. CNSs help to reduce healthcare costs when the roles are fully deployed and all the dimensions of the CNS role are implemented. The dimensions of the CNS role include clinical care, organizational leadership, research, education, professional development and consultation to provide patient care. There is a paucity of research on CNSs in Canada. We conducted the first Canada-wide survey of CNSs and asked each nursing regulatory body to identify the CNSs in their registration database. One-quarter (n=196/776) of the regulator-identified CNS respondents whom we contacted for the study were no longer or had never been a CNS. Currently, adequate mechanisms are lacking to identify and track CNSs in Canada, and little is known about the factors that influence CNSs' decisions to leave their role. The non-employed CNS respondents in our survey highlighted that the lack of role clarity, their inability to find employment as a CNS and the inability to implement all the dimensions of the CNS role were key factors in their decision not to work as a CNS. These findings have important implications, given that these factors are potentially modifiable and amenable to decisions made by nursing leaders in organizations and regulatory bodies. Mechanisms to identify and track CNSs in Canada are needed to develop an effective workforce plan and maximize the integration of CNSs in the workforce.
    Nursing leadership (Toronto, Ont.) 05/2014; 27(1):62-75. DOI:10.12927/cjnl.2014.23738
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    ABSTRACT: In Canada, adolescent survivors of cancer are treated mainly at pediatric centers, while young adults are treated at adult centers. Both care environments are reported as being inappropriate and do not fulfill the needs of adolescents and young adults (AYA). The purpose of this study was to investigate supportive care needs (SCN) of AYA survivors of cancer. Qualitative description and a systematic literature review (SLR) were used to explore this topic. For the qualitative study, a purposive sample of AYA survivors (15 to 25 years of age) was recruited from a pediatric and an adult cancer program in one area of Ontario, Canada. Interviews were conducted, recorded digitally, and transcribed verbatim. Line-by-line coding was used to establish themes and subthemes. The SLR entailed a systematic search of electronic databases from their date of inception to October 2011. Two screeners worked independently to screen abstracts, titles, and relevant full-text articles. Findings from both studies were synthesized. Twenty interviews were conducted for the qualitative study. For the SLR, 760 citations were identified, of which 12 met inclusion criteria. The most commonly reported SCN, from both studies, were social needs, information sharing and communication needs, and service provision needs. Comparison of findings from both studies reveals many overlapping (e.g., entertainment for teens) and novel (e.g., collaboration) themes. Study results will be used to inform the potential development of a comprehensive healthcare program for AYA.
    Supportive Care in Cancer 11/2013; DOI:10.1007/s00520-013-2053-7 · 2.50 Impact Factor
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    ABSTRACT: Clinical nurse specialists are recognized internationally for providing an advanced level of practice. They positively impact the delivery of healthcare services by using specialty-specific expert knowledge and skills, and integrating competencies as clinicians, educators, researchers, consultants and leaders. Graduate-level education is recommended for the role but many countries do not have formal credentialing mechanisms for clinical nurse specialists. Previous studies have found that clinical nurse specialist roles are poorly understood by stakeholders. Few national studies have examined the utilization of clinical nurse specialists.
    International journal of nursing studies 03/2013; 50(11). DOI:10.1016/j.ijnurstu.2013.03.005 · 2.25 Impact Factor
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    Nancy Carter · Denise Bryant-Lukosius · Alba DiCenso · Jennifer Blythe · Alan J Neville
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    ABSTRACT: To better understand the priority supportive care needs of men with advanced prostate cancer. Qualitative, descriptive study. Outpatient cancer center and urology clinics in central western Ontario, Canada. 12 men with hormone-sensitive prostate cancer and 17 men with hormone-refractory prostate cancer. Patients participated in focus groups and interviews that examined their supportive care needs, their priority needs, and suggestions for improvements to the delivery of care. Tape-recorded focus group discussions and interviews were organized using NVivo software. Patients' supportive care needs. Participants identified prostate cancer-specific information and support to maintain their ability "to do what they want to do" as priority needs. Both hormone-sensitive and hormone-refractory groups cited problems with urinary function, the side effects of treatment, fatigue, and sexual concerns as major functional issues. Participants experienced emotional distress related to diagnosis and treatment. A priority health need for men with advanced prostate cancer is to improve or maintain functional abilities. In addition, men require support to meet their stage-specific information needs and to address concerns about the diagnosis and ambivalent feelings about past treatment decisions. Nurses could play an important role in addressing men's information needs and providing emotional support. The complex care needs of men with advanced prostate cancer provide opportunity for the development of advanced practice nurse roles that would use the clinical and nonclinical aspects of the role.
    Oncology Nursing Forum 03/2011; 38(2):189-98. DOI:10.1188/11.ONF.189-198 · 1.91 Impact Factor
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    ABSTRACT: Title confusion and lack of role clarity pose barriers to the integration of advanced practice nursing roles (i.e., clinical nurse specialist [CNS] and nurse practitioner [NP]). Lack of awareness and understanding about NP and CNS roles among the healthcare team and the public contributes to ambiguous role expectations, confusion about NP and CNS scopes of practice and turf protection. This paper draws on the results of a scoping review of the literature and qualitative key informant interviews conducted for a decision support synthesis commissioned by the Canadian Health Services Research Foundation and the Office of Nursing Policy in Health Canada. The goal of this synthesis was to develop a better understanding of advanced practice nursing roles and the factors that influence their effective development and integration in the Canadian healthcare system. Specific recommendations from interview participants and the literature to enhance title and role clarity included the use of consistent titles for NP and CNS roles; the creation of a vision statement to articulate the role of CNSs and NPs across settings; the use of a systematic planning process to guide role development and implementation; the development of a communication strategy to educate healthcare professionals, the public and employers about the roles; attention to inter-professional team dynamics when introducing these new roles; and addressing inter-professionalism in all health professional education program curricula.
    Nursing leadership (Toronto, Ont.) 12/2010; 23 Spec No 2010:189-201. DOI:10.12927/cjnl.2010.22276
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    ABSTRACT: Although advanced practice nurses (APNs) have existed in Canada for over 40 years and there is abundant evidence of their safety and effectiveness, their full integration into our healthcare system has not been fully realized. For this paper, we drew on pertinent sections of a scoping review of the Canadian literature from 1990 onward and interviews or focus groups with 81 key informants conducted for a decision support synthesis on advanced practice nursing to identify the factors that enable role development and implementation across the three types of APNs: clinical nurse specialists, primary healthcare nurse practitioners and acute care nurse practitioners. For development of advanced practice nursing roles, many of the enabling factors occur at the federal/provincial/territorial (F/P/T) level. They include utilization of a pan-Canadian approach, provision of high-quality education, and development of appropriate legislative and regulatory mechanisms. Systematic planning to guide role development is needed at both the F/P/T and organizational levels. For implementation of advanced practice nursing roles, some of the enabling factors require action at the F/P/T level. They include recruitment and retention, role funding, intra-professional relations between clinical nurse specialists and nurse practitioners, public awareness, national leadership support and role evaluation. Factors requiring action at the level of the organization include role clarity, healthcare setting support, implementation of all role components and continuing education. Finally, inter-professional relations require action at both the F/P/T and organizational levels. A multidisciplinary roundtable formulated policy and practice recommendations based on the synthesis findings, and these are summarized in this paper.
    Nursing leadership (Toronto, Ont.) 12/2010; 23 Spec No 2010:211-38. DOI:10.12927/cjnl.2010.22279
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    ABSTRACT: The objective of this decision support synthesis was to identify and review published and grey literature and to conduct stakeholder interviews to (1) describe the distinguishing characteristics of clinical nurse specialist (CNS) and nurse practitioner (NP) role definitions and competencies relevant to Canadian contexts, (2) identify the key barriers and facilitators for the effective development and utilization of CNS and NP roles and (3) inform the development of evidence-based recommendations for the individual, organizational and system supports required to better integrate CNS and NP roles into the Canadian healthcare system and advance the delivery of nursing and patient care services in Canada. Four types of advanced practice nurses (APNs) were the focus: CNSs, primary healthcare nurse practitioners (PHCNPs), acute care nurse practitioners (ACNPs) and a blended CNS/NP role. We worked with a multidisciplinary, multijurisdictional advisory board that helped identify documents and key informant interviewees, develop interview questions and formulate implications from our findings. We included 468 published and unpublished English- and French-language papers in a scoping review of the literature. We conducted interviews in English and French with 62 Canadian and international key informants (APNs, healthcare administrators, policy makers, nursing regulators, educators, physicians and other team members). We conducted four focus groups with a total of 19 APNs, educators, administrators and policy makers. A multidisciplinary roundtable convened by the Canadian Health Services Research Foundation formulated evidence-informed policy and practice recommendations based on the synthesis findings. This paper forms the foundation for this special issue, which contains 10 papers summarizing different dimensions of our synthesis. Here, we summarize the synthesis methods and the recommendations formulated at the roundtable.
    Nursing leadership (Toronto, Ont.) 12/2010; 23 Spec No 2010:15-34. DOI:10.12927/cjnl.2010.22267
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    ABSTRACT: The clinical nurse specialist (CNS) provides an important clinical leadership role for the nursing profession and broader healthcare system; yet the prominence and deployment of this role have fluctuated in Canada over the past 40 years. This paper draws on the results of a decision support synthesis examining advanced practice nursing roles in Canada. The synthesis included a scoping review of the Canadian and international literature and in-depth interviews with key informants including CNSs, nurse practitioners, other health providers, educators, healthcare administrators, nursing regulators and government policy makers. Key challenges to the full integration of CNSs in the Canadian healthcare system include the paucity of Canadian research to inform CNS role implementation, absence of a common vision for the CNS role in Canada, lack of a CNS credentialing mechanism and limited access to CNS-specific graduate education. Recommendations for maximizing the potential and long-term sustainability of the CNS role to achieve important patient, provider and health system outcomes in Canada are provided.
    Nursing leadership (Toronto, Ont.) 12/2010; 23 Spec No 2010(sp):140-66. DOI:10.12927/cjnl.2010.22273
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    ABSTRACT: The acute care nurse practitioner (ACNP) role was developed in Canada in the late 1980s to offset rapidly increasing physician workloads in acute care settings and to address the lack of continuity of care for seriously ill patients and increased complexity of care delivery. These challenges provided an opportunity to develop an advanced practice nursing role to care for critically ill patients with the intent of improving continuity of care and patient outcomes. For this paper, we drew on the ACNP-related findings of a scoping review of the literature and key informant interviews conducted for a decision support synthesis on advanced practice nursing. The synthesis revealed that ACNPs are working in a range of clinical settings. While ACNPs are trained at the master's level, there is a gap in specialty education for ACNPs. Important barriers to the full integration of ACNP roles into the Canadian healthcare system include lack of full utilization of role components, limitations to scope of practice, inconsistent team acceptance and funding issues. Facilitators to ACNP role implementation include clear communication about the role, with messages tailored to the specific information needs of various stakeholder groups; supportive leadership of healthcare managers; and stable and predictable funding. The status of ACNP roles continues to evolve across Canada. Ongoing leadership and continuing research are required to enhance the integration of these roles into our healthcare system.
    Nursing leadership (Toronto, Ont.) 12/2010; 23 Spec No 2010(sp):114-39. DOI:10.12927/cjnl.2010.22272
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    ABSTRACT: In Canada, education programs for the clinical nurse specialist (CNS) and nurse practitioner (NP) roles began 40 years ago. NP programs are offered in almost all provinces. Education for the CNS role has occurred through graduate nursing programs generically defined as providing preparation for advanced nursing practice. For this paper, we drew on pertinent sections of a scoping review of the literature and key informant interviews conducted for a decision support synthesis on advanced practice nursing to describe the following: (1) history of advanced practice nursing education in Canada, (2) current status of advanced practice nursing education in Canada, (3) curriculum issues, (4) interprofessional education, (5) resources for education and (6) continuing education. Although national frameworks defining advanced nursing practice and NP competencies provide some direction for education programs, Canada does not have countrywide standards of education for either the NP or CNS role. Inconsistency in the educational requirements for primary healthcare NPs continues to cause significant problems and interferes with inter-jurisdictional licensing portability. For both CNSs and NPs, there can be a mismatch between a generalized education and specialized practice. The value of interprofessional education in facilitating effective teamwork is emphasized. Recommendations for future directions for advanced practice nursing education are offered.
    Nursing leadership (Toronto, Ont.) 12/2010; 23 Spec No 2010:61-84. DOI:10.12927/cjnl.2010.22269
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    ABSTRACT: In the past decade, all Canadian provinces and territories have launched various team-based primary healthcare initiatives designed to improve access and continuity of care. Nurse practitioners (NPs) are increasingly becoming integral members of primary healthcare teams across the country. This paper draws on the results of a scoping review of the literature and qualitative key informant interviews conducted for a decision support synthesis about advanced practice nursing in Canada. We describe and analyze two novel approaches to NP integration designed to address the gap in patient access to primary healthcare: (1) the integration of NPs in traditional fee-for-service practices in British Columbia, and (2) the creation of NP-led clinics in Ontario. Although fee-for-service remuneration has been a barrier to collaborative practice, the integration of government-salaried NPs into fee-for-service practices in British Columbia has enabled the creation of inter-professional teams, and based on early evaluation findings, has increased patient access to care and patient and provider satisfaction. NP-led clinics are designed to provide inter-professional care in communities with high numbers of patients who do not have a regular primary healthcare provider. Given the shortage of physicians in communities where these clinics are being introduced, the ratio of physicians to NPs is lower than in other primary healthcare delivery models, and physicians function in more of a consulting role. Initial evaluation of the first of 26 NP-led clinics indicates increased access to care and high levels of patient and provider satisfaction. Implementing a creative mosaic of collaborative primary healthcare models that are responsive to patient needs challenges traditional assumptions about professional roles and responsibilities. To address this challenge, we endorse a recommendation that governments establish a mechanism to bring together both physician and non-physician primary healthcare providers to advise on primary healthcare policy development and implementation.
    Nursing leadership (Toronto, Ont.) 12/2010; 23 Spec No 2010:239-59. DOI:10.12927/cjnl.2010.22281

Publication Stats

481 Citations
21.06 Total Impact Points

Institutions

  • 2003–2015
    • McMaster University
      • School of Nursing
      Hamilton, Ontario, Canada
  • 2010
    • Dalhousie University
      • School of Nursing
      Halifax, Nova Scotia, Canada
    • Ryerson University
      Toronto, Ontario, Canada
    • Université du Québec en Outaouais
      Gatineau, Quebec, Canada