Norma J Stewart

University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Are you Norma J Stewart?

Claim your profile

Publications (58)75.42 Total impact

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Aim To report the development and psychometric evaluation of a scale to measure rural and remote (rural/remote) nurses' perceptions of the engagement of their workplaces in key dimensions of primary health care (PHC). Amidst ongoing PHC reforms, a comprehensive instrument is needed to evaluate the degree to which rural/remote health care settings are involved in the key dimensions that characterize PHC delivery, particularly from the perspective of professionals delivering care. This study followed a three-phase process of instrument development and psychometric evaluation. A literature review and expert consultation informed instrument development in the first phase, followed by an iterative process of content evaluation in the second phase. In the final phase, a pilot survey was undertaken and item discrimination analysis employed to evaluate the internal consistency reliability of each subscale in the preliminary 60-item Primary Health Care Engagement (PHCE) Scale. The 60-item scale was subsequently refined to a 40-item instrument. Findings The pilot survey sample included 89 nurses in current practice who had experience in rural/remote practice settings. Participants completed either a web-based or paper survey from September to December, 2013. Following item discrimination analysis, the 60-item instrument was refined to a 40-item PHCE Scale consisting of 10 subscales, each including three to five items. Alpha estimates of the 10 refined subscales ranged from 0.61 to 0.83, with seven of the subscales demonstrating acceptable reliability (α⩾0.70). The refined 40-item instrument exhibited good internal consistency reliability (α=0.91). The 40-item PHCE Scale may be considered for use in future studies regardless of locale, to measure the extent to which health care professionals perceive their workplaces to be engaged in key dimensions of PHC.
    Full-text · Article · Jan 2016 · Primary Health Care Research & Development
  • [Show abstract] [Hide abstract]
    ABSTRACT: Community-based services are important for improving outcomes for individuals with dementia and their caregivers. This study examined: (1) availability of rural dementia-related services in the Canadian province of Saskatchewan, and (2) orientation of services toward six key attributes of primary health care (i.e., information/education, accessibility, population orientation, coordinated care, comprehensiveness, quality of care). Data were collected from 71 rural Home Care Assessors via cross-sectional survey. Basic health services were available in most communities (e.g., pharmacists, family physicians, palliative care, adult day programs, home care, long-term care facilities). Dementia-specific services typically were unavailable (e.g., health promotion, counselling, caregiver support groups, transportation, week-end/night respite). Mean scores on the primary health care orientation scales were low (range 12.4 to 17.5/25). Specific services to address needs of rural individuals with dementia and their caregivers are limited in availability and fit with primary health care attributes.
    No preview · Article · Oct 2015 · Home Health Care Services Quarterly
  • [Show abstract] [Hide abstract]
    ABSTRACT: An understanding of the specific dementia learning needs of home care staff is needed to plan relevant continuing education (CE) programs and supports. The study’s objective was to examine frequency and perceived competence in performing 20 dementia-related work activities, and identify CE priorities among home care staff. A cross-sectional survey of all home care staff in a primarily rural health region was used to gather data. Of 111 eligible staff, 82 participated (41 nursing aides, 41 nurses/case managers). To explore the relationship between activity frequency (F) and competence (C), the proportion of nurses and aides in four quadrants for each activity was examined: (1) low F-low C, (2) low F-high C, (3) high F-low C, and (4) high F-high C. Nurses/case managers were significantly more likely than aides to regularly perform 11 activities and to report high competence in 9 activities (p < .05); aides were more likely to assist with two activities (personal care and daily living activities). Thus, nurses/case managers performed a broader range of activities and reported higher competence overall. The top CE topic for both groups was recognizing differences between dementia subtypes, but rankings for most activities varied by group. Aides’ CE priorities indicated a desire to develop competence in low frequency-low competence activities, suggesting an expanded role in supporting dementia patients and their families. Nurses’ CE priority topics were in the high F-high C quadrant, indicating a need to further develop competence in these activities. Findings have implications for planning CE programming for home care providers.
    No preview · Article · Sep 2015 · Educational Gerontology
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Determining the epidemiology of dementia among the population as a whole in specific jurisdictions - including the long-term care population-is essential to providing appropriate care. The objectives of this study were to use linked administrative databases in the province of Saskatchewan to determine the 12-month incidence and prevalence of dementia for the 2012/13 period (1) among individuals aged 45 and older in the province of Saskatchewan, (2) according to age group and sex, and (3) according to diagnosis code and other case definition criteria. Methods: We used a population-based retrospective cohort study design and extracted data from 10 provincial health databases linked by a unique health services number. The cohort included individuals 45 years and older at first identification of dementia between April 1, 2001 and March 31, 2013 based on case definitions met within any one of four administrative health databases (Hospital Discharge Abstracts, Physician Service Claims, Prescription Drug, and RAI-MDS, i.e., Long-term Care). Results: A total of 3,270 incident cases of dementia (7.28 per 1,000 PAR) and 13,012 prevalent cases (28.16 per 1,000 PAR) were identified during 2012/13. This study found the incidence rate increased by 2.8 to 5.1 times and the prevalence rate increased by 2.6 to 4.6 times every 10 years after 45 years of age. Overall, the age-standardised incidence rate was significantly lower among females than males (7.04 vs. 7.65 per 1,000 PAR) and the age-standardised prevalence rate was significantly higher among females than males (28.92 vs. 26.53 per 1,000 PAR). Over one-quarter (28 %) of all incident cases were admitted to long-term care before a diagnosis was formally recorded in physician or hospital data, and nearly two-thirds of these cases were identified at admission with impairment at the moderate to very severe level or a disease category of Alzheimer's disease/other dementia. Conclusions: Linking multiple sources of registry data contributes to our understanding of the epidemiology of dementia across multiple segments of the population, inclusive of individuals residing in long-term care. This information is foundational for public awareness and policy recommendations, health promotion and prevention strategies, appropriate health resource planning, and research priorities.
    Full-text · Article · Jul 2015 · BMC Geriatrics
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study assessed individual and organizational context (work environment) factors that influence use of best practices by care aides (nursing assistants) in nursing homes. Little scientific attention has been focused on understanding best practice use in nursing homes and almost none on care aides. A total of 1262 care aides in 25 nursing homes in the 3 Canadian prairie provinces. Care aides are unregulated workers who provide 80% of direct care to residents in Canadian nursing homes. We used hierarchical linear modeling to (1) assess the amount of variance in use of best practices, as reported by care aides, that could be attributed to individual or organizational factors, and (2) identify predictors of best practices use by care aides. At the individual level, statistically significant predictors of instrumental use of best practices included sex, age, shift worked, job efficacy, and belief suspension. At the unit level, significant predictors were social capital, organizational slack (staffing and time), number of informal interactions, and unit type. At the facility level, ownership model and province were significant. Significant predictors of conceptual use of best practices at the individual level included English as a first language, job efficacy, belief suspension, intent to use research, adequate knowledge, and number of information sources used. At the unit level, significant predictors were evaluation (feedback mechanisms), structural resources, and organizational slack (time). At the facility level, province was significant. The R(2) was 18.3% for instrumental use of best practices and 43.4% for conceptual use. Unit level factors added a substantial amount of explained variance whereas facility level factors added relatively little explained variance. Our study suggests that context plays an important role in care aides' use of best practices in nursing homes. Individual characteristics played a more prominent role than contextual factors in predicting conceptual use of best practices. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Apr 2015 · Journal of the American Medical Directors Association
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Community–based participatory research (CBPR) approaches are valuable strategies for addressing complex health and social problems and powerful tools to support effective transformation of social and health policy to better meet the needs of diverse stakeholders. Objectives: Since 1997, our team has utilized CBPR approaches to improve health service delivery for persons with dementia and their caregivers in rural and remote settings. We describe the evolution of our approach, including benefits, challenges, and lessons learned over the last 15 years. Methods: A multistage approach initiated an ongoing CBPR research program in rural dementia care and shaped its direction based on stakeholders’ recommendation to prioritize both community and facility–based care. Strategies to develop and foster collaborative partnerships have included travel to rural and remote regions, province–wide community meetings, stakeholder workshops, creation of a Decision–Maker Advisory Council to provide ongoing direction to the overall program, development of diverse project–specific advisory groups, and a highly successful and much anticipated annual knowledge exchange and team–building event. Lessons Learned: Partnering with stakeholders in the full research process has enhanced the research quality, relevance, application, and sustainability. These benefits have supported the team’s evolution from a relatively traditional focus to an integrated approach guiding all aspects of our research. Conclusions: Developing and sustaining the full range of stakeholder and decision–maker partnerships is resource–and time–intensive, but our experience shows that community–based participatory strategies are highly suited to health services research that is designed to support sustainable service delivery improvements.
    No preview · Article · Dec 2014 · Progress in Community Health Partnerships Research Education and Action
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Patient satisfaction is a key aspect of quality of care and can inform continuous quality improvement. Of the few studies that have reported on patient satisfaction with telehealth in programs aimed at individuals with memory problems, none has reported on the psychometric properties of the user satisfaction scales used. Materials and methods: We evaluated the construct validity and internal consistency reliability of the Telehealth Satisfaction Scale (TeSS), a 10-item scale adapted for use in a rural and remote memory clinic (RRMC). The RRMC is a one-stop interprofessional clinic for rural and remote seniors with suspected dementia, located in a tertiary-care hospital. Telehealth videoconferencing is used for preclinic assessment and for follow-up. Patients and caregivers completed the TeSS after each telehealth appointment. With data from 223 patients, exploratory factor analysis was conducted using the principal components analysis extraction method. Results: The eigenvalue for the first factor (5.2) was greater than 1 and much larger than the second eigenvalue (0.92), supporting a one-factor solution that was confirmed by the scree plot. The total variance explained by factor 1 was 52.1%. Factor loadings (range, 0.54-0.84) were above recommended cutoffs. The TeSS items demonstrated high internal consistency reliability (Cronbach's alpha=0.90). Satisfaction scores on the TeSS items ranged from 3.43 to 3.72 on a 4-point Likert scale, indicating high satisfaction with telehealth. Conclusions: The study findings demonstrate high user satisfaction with telehealth in a rural memory clinic and the sound psychometric properties of the TeSS in this population.
    No preview · Article · Oct 2014 · Telemedicine and e-Health
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Rural and remote settings pose particular healthcare and service delivery challenges. Providing appropriate care and support for individuals with dementia and their families living in these communities is especially difficult, and can only be accomplished when the needs of care providers and the context and complexity of care provision are understood. This paper describes formal and informal caregivers’ perceptions of the challenges and needs in providing care and support for individuals with dementia living in rural and remote areas of Saskatchewan, Canada. Methods: A mixed-methods exploratory approach was used to examine caregivers’ needs. This research was a component of a broader process evaluation designed to inform the initial and ongoing development of a community-based participatory research program in rural dementia care, which included the development of the Rural and Remote Memory Clinic (RRMC). Four approaches were used for data collection and analyses: (1) thematic analysis of consultation meetings with rural healthcare providers: documented discussions from consultation meetings that occurred in 2003–2004 with rural physicians and healthcare providers regarding plans for a new RRMC were analysed thematically; (2) telephone and mail questionnaires: consultation meeting participants completed a subsequent telephone or mail questionnaire (2003–2004) that was analysed descriptively; (3) thematic analysis of referral letters to the Rural and Remote Memory Clinic: physician referral letters over a five-year period (2003–2008) were analysed descriptively and thematically; and (4) examination of family caregiver satisfaction: four specific baseline questionnaire questions completed by family caregivers (2007–2010) were analysed descriptively and thematically. Results: Both physician and non-physician healthcare providers identified increased facilities and care programs as needs. Physicians were much more likely than other providers to report available support services for patients and families as adequate. Non-physician providers identified improved services, better coordination of services, travel and travel burden related needs, and staff training and education needs as priorities. Physician needs, as determined via referral letters, included confirmation of diagnosis or treatment, request for further management suggestions, patient or family request, and consultation regarding difficult cases. One-third of informal caregivers expressed not being satisfied with the care received prior to the Rural and Remote Memory Clinic assessment visit, and identified lack of diagnosis and long wait times for services as key issues. Conclusions: Delivering services and providing care and support for individuals with dementia living in rural and remote communities are especially challenging. The need for increased extent of services was a commonality among formal and informal caregivers. Primary care physicians may seek confirmation of their diagnosis or may need assistance when dealing with difficult aspects of care, as identified by referral letters. Differences between the needs identified via referral letters and questionnaire responses of physicians may be a reflection of the rural or remote context of care provision. Informal caregiver needs were more aligned with non-physician healthcare providers with respect to the need for improved access to additional healthcare professionals and services. The findings have implications for regional policy development that addresses human and other resource shortages.
    Full-text · Article · Aug 2014 · Rural and remote health
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background/Aims To estimate the prevalence, severity, and covariates of depressive symptoms in rural memory clinic patients diagnosed with either mild cognitive impairment (MCI) or dementia. Methods In a cross-sectional study of 216 rural individuals who attended an interdisciplinary memory clinic between March 2004 and July 2012, 51 patients were diagnosed with MCI and 165 with either dementia due to Alzheimer's disease (AD) or non-AD dementia. The Center for Epidemiologic Studies of Depression Scale (CES-D) was used to estimate the severity and prevalence of clinically elevated depressive symptomatology. Results The prevalence of elevated depressive symptoms was 51.0% in the MCI patients and 30.9% in the dementia patients. Depressive symptoms were more severe in the MCI patients than in the dementia patients. Elevated depressive symptoms were statistically associated with younger age for the MCI group, with lower self-rated memory for the dementia group, and with increased alcohol use and lower quality of life ratings for all patients. In the logistic regression models, elevated depressive symptoms remained negatively associated with self-rated memory and quality of life for the patients with dementia, but significant bivariate associations did not persist in the MCI group. Conclusions The high prevalence and severity of depressive symptoms among rural memory clinic patients diagnosed with either MCI or dementia warrant continued investigation.
    Full-text · Article · Jul 2014
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Caregiving in a rural context is unique, but the experience of rural caregivers is understudied. This paper describes how rural caregivers cope with caring for a loved one diagnosed with mild cognitive impairment or dementia using qualitative description to generate a low-inference summary of a response to an open-ended question. This approach allowed these rural caregivers to describe their positive experiences in addition to the more commonly explored caregiver experiences related to stress. Analyses of coping revealed use of social support, engaging in relaxing and physical activity, and cognitive reframing. In addition, caregivers reported strong faith and religiosity, and to a lesser frequency behavioral changes, checking in with the person with dementia via telephone, and joint activity. Predominantly, these methods reflect approach-based strategies. The current data suggest that these caregivers manage well and adopt adaptive coping strategies to meet the demands of the caregiving role.
    Full-text · Article · Jun 2014 · Dementia
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although only 20–50% of individuals with dementia are diagnosed, early diagnosis enables patients and families to access interventions and services, and plan for the future. The current study explored the experiences of rural family caregivers in the period leading up to a diagnostic assessment at a Canadian memory clinic, their hopes and expectations of the assessment, and their experiences in the six months following diagnosis. Using a longitudinal, retrospective and prospective qualitative research design, caregivers of 30 patients referred to the clinic were interviewed during the diagnostic assessment process and again six months after the diagnosis. Most caregivers reported first noticing symptoms two years prior to diagnosis. The pre-diagnostic interviews revealed a prevalent ‘need to know’ among caregivers that drove the help-seeking process. Caregivers hoped that the diagnosis would have the benefits of ‘naming it,’ ‘accessing treatment,’ ‘knowing what to expect,’ and ‘receiving guidance.’ When asked six months later about the impact of the diagnosis, the main theme was ‘acceptance and moving forward.’ Caregivers reported that the diagnosis provided ‘relief,’ ‘validation,’ and ‘improved access to services.’ These findings can inform care practices of primary health care providers who represent the first point of contact regarding expectations and experiences of dementia-related diagnoses.
    No preview · Article · Feb 2014 · Social Science [?] Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Forecasts of increasing prevalence of dementia in rural settings, coupled with reliance on family caregiver support, indicate that a greater understanding of caregiver distress in these contexts is necessary. The purpose of this study was to examine family caregiver burden and severity of distress on the day that a family member was diagnosed with dementia at a memory clinic that serves a rural population. Participants in this retrospective study were 231 primary family caregivers of a rural community-dwelling person with dementia. On the diagnostic day, women reported more burden and severity of distress than men and spouses reported more severity of distress than adult children. A structural equation model was not supported for the entire sample, but was supported for women caregivers only (n = 161). Caregiver distress related to dementia-specific behaviors explained both global distress and burden. Patients' functional decline was related to caregiver burden.
    No preview · Article · Jan 2014
  • [Show abstract] [Hide abstract]
    ABSTRACT: Earlier research suggests that geographic location matters for informal caregivers of persons with dementia: rural caregivers tend to rely on more informal supports and may report more psychological distress and burden than urban caregivers. Differential access to services may underlie these findings, but degree of rurality is typically measured with population size. In contrast, the current article measured degree of rurality with standardized scale of access to metropolitan centers. In a large sample we found nonsignificant and trivial associations between metropolitan access with self-reported caregiver distress, (N = 272; Brief Symptom Inventory), burden (N = 234; Zarit Burden Interview), and coping (n = 46; Jalowiec Coping Scale). The null findings were likely related to the use of a proxy variable for dementia-related caregiver supports (i.e., degree of access to metropolitan centers). In future research, direct measures of access to appropriate dementia related services should be used to study caregiver outcomes.
    No preview · Article · Dec 2013 · Journal of Applied Gerontology
  • [Show abstract] [Hide abstract]
    ABSTRACT: ABSTRACT Nursing homes have become complex care environments where residents have significant needs and most have age-related dementia. Building on research by Hirdes et al. (2011), we describe a resident profile in a representative sample of 30 urban nursing homes in the prairie provinces using Resident Assessment Instrument - Minimum Data Set 2.0 data from 5,196 resident assessments completed between 1 October 2007 and 31 December 2011. Residents were chiefly over age 85, female, and with an age-related dementia. We compared facility support and related services and resident characteristics by province, owner-operator model, and number of facility units. We observed differences in support and related services by both unit count and province. We also found that public facilities tend to care for residents with more demanding characteristics: notably cognitive impairment, aggressive behaviours, and incontinence. No clear trends associating the number of units in a facility with resident characteristics were observed.
    No preview · Article · Aug 2013 · Canadian Journal on Aging / La Revue canadienne du vieillissement
  • [Show abstract] [Hide abstract]
    ABSTRACT: Context is increasingly recognized as a key factor to be considered when addressing healthcare practice. This study describes features of context as they pertain to knowledge use in long-term care (LTC). As one component of the research program Translating Research in Elder Care, an in-depth qualitative case study was conducted to examine the research question "How does organizational context mediate the use of knowledge in practice in long-term care facilities?" A representative facility was chosen from the province of Saskatchewan, Canada. Data included document review, direct observation of daily care practices, and interviews with direct care, allied provider, and administrative staff. The Hidden Complexity of Long-Term Care model consists of 8 categories that enmesh to create a context within which knowledge exchange and best practice are executed. These categories range from the most easily identifiable to the least observable: physical environment, resources, ambiguity, flux, relationships, and philosophies. Two categories (experience and confidence, leadership and mentoring) mediate the impact of other contextual factors. Inappropriate physical environments, inadequate resources, ambiguous situations, continual change, multiple relationships, and contradictory philosophies make for a complicated context that impacts care provision. A hidden complexity underlays healthcare practices in LTC and each care provider must negotiate this complexity when providing care. Attending to this complexity in which care decisions are made will lead to improvements in knowledge exchange mechanisms and best practice uptake in LTC settings.
    No preview · Article · Jul 2013 · The Gerontologist
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Little is known about the views of rural family physicians (FPs) regarding collaborative care models for patients with dementia. The study aims were to explore FPs’ views regarding this issue, their role in providing dementia care, and the implications of providing dementia care in a rural setting. This study employed an exploratory qualitative design with a sample of 15 FPs. All rural FPs indicated acceptance of collaborative models. The main disadvantages of practicing rural were accessing urban-based health care and related services and a shortage of local health care resources. The primary benefit of practicing rural was FPs’ social proximity to patients, families, and some health care workers. Rural FPs provided care for patients with dementia that took into account the emotional and practical needs of caregivers and families. FPs described positive and negative implications of rural dementia care, and all were receptive to models of care that included other health care professionals.
    Full-text · Article · Apr 2013 · Primary Health Care Research & Development
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE:: Symptoms of nausea and vomiting are commonly experienced during early pregnancy (nausea and vomiting of pregnancy or NVP) and have been associated with stress, anxiety, and depression in pregnancy. However, nausea and vomiting in late pregnancy is a little-studied phenomenon. The purpose of our study was to examine the prevalence, severity, and psychosocial determinants of NVP during early and late pregnancy. STUDY DESIGN AND METHODS:: Data were originally from a longitudinal and epidemiological study of depression in pregnancy and postpartum in a cohort of 648 Canadian women conducted from 2005 to 2008. Measures included the Nausea and Vomiting in Pregnancy Instrument (NVPI), the Cambridge Worry Scale (CWS), and the Edinburgh Postnatal Depression Scale (EPDS). Demographic, maternal/obstetrical, psychological, and behavioral variables related to NVP were also examined. Odds ratios and 95% confidence intervals were calculated for all risk factors investigated using multiple logistic regression, controlling for potential confounders. RESULTS:: The prevalence of NVP was 63.3% (n = 551) at Time 1 (early pregnancy) and 45.4% (n = 575) at Time 2 (late pregnancy). Severity of symptoms was associated with earlier gestation, antiemetic medication use, employment status, and symptoms of major depression. Maternal smoking and having the support of three or more persons were protective for NVP. CLINICAL IMPLICATIONS:: This study suggests that screening for NVP should be ongoing throughout pregnancy and measures that address NVP, poor social support, and depression are warranted. Further research is needed in regard to effective management of this very common and distressing condition.
    Full-text · Article · Jan 2013 · MCN. The American journal of maternal child nursing
  • Source

    Full-text · Conference Paper · Jul 2012
  • Mary E Andrews · Norma J Stewart · Debra G Morgan · Carl D'Arcy
    [Show abstract] [Hide abstract]
    ABSTRACT: To explore gender differences and similarities on personal, employment and work-life factors and predictors of job satisfaction among registered nurses in rural and remote Canada. Research suggests that men and women are attracted to nursing for different reasons, with job security, range of employment opportunities and wages being important for male nurses. Using data from a large national survey of registered nurses in rural and remote Canada, descriptive and multiple linear regression analyses were used to identify gender differences and similarities. A larger proportion of male nurses reported experiencing aggression in the workplace. Age, annual gross income and colleague support in medicine were not found to be predictors of work satisfaction for the male nurses, although they were for women. There are more similarities than differences between male and female registered nurses in factors that affect job satisfaction. Nursing management needs to increase their awareness of the potential for workplace aggression towards male registered nurses and to explore the perceptions of interpersonal interactions that affect satisfaction in the workplace.
    No preview · Article · May 2012 · Journal of Nursing Management
  • Source
    Kelly L Penz Mn · Norma J Stewart
    [Show abstract] [Hide abstract]
    ABSTRACT: In a secondary analysis of a national survey of Registered Nurses (RNs) working in rural and remote Canada, two groups of acute care nurses were compared on the work satisfaction variables of autonomy and nurse-physician interaction based on whether their workplace community population was rural (10,000 or less) or small urban (>10,000 but <100,000). For this analysis, the variable "size of community" served as a proxy indicator for hospital size. Kanter's (1993) theory on the structure of power in organizations was the basis of the hypotheses. As predicted, the rural RNs (n=811) working in the smaller hospital organizations had significantly higher levels of autonomy [F(1, 1229)= 5.602, p<0.05] and higher levels of nurse-physician interaction [F(1, 1229)=27.78, p<0.001] than the small urban RNs (n=427). The findings suggest that the size of an organization or hospital setting does have an influence on the level of autonomous practice and interaction between nurses and physicians.
    Full-text · Article · Jan 2012