The Joanna Briggs Institute (JBI) and Lippincott NursingCenter – what a pair!


joanna-briggs-institute.jpgIf you haven’t noticed already, Lippincott NursingCenter hosts a wide variety of content from the Joanna Briggs Institute (JBI). JBI is a leading international research and development organization based within the Faculty of Health Sciences at the University of Adelaide, South Australia. It promotes and supports the synthesis and transfer of evidence-based practice information to health care professionals to support clinical decision-making. As a leading provider of nursing resources based on the best evidence available, it only makes sense that NursingCenter would partner with JBI to provide the most up-to-date and authoritative nursing content. 

jbi-database-of-systematic-reviews-and-implementation-reports.jpegMost recently, Wolters Kluwer became the publisher of the 
JBI Database of Systematic Reviews and 
Implementation Reports (JBISRIR)
, an online journal that publishes systematic 
review protocols and systematic reviews of health care research on a monthly basis. I’m actually the digital editor for this journal, and I am proud to say the editorial team behind this content is incredibly dedicated to providing reports that are based on JBI methodology and present the findings of projects that seek to implement the best available evidence into practice. You can find JBISRIR on NursingCenter. For all of the past issues and information for authors, please visit the journal website

There’s also a new JBI CE course hosted on NursingCenter, the Experiences of Heart Failure Patients Following Their Participation in Self-Management Patient Education. Learn how to recognize the components of a self-management education program for patients with heart failure and earn one contact hour. In fact, there’s over 50 JBI CE courses hosted on NursingCenter, including JBI Best Practice, JBI Long Courses, and JBI Evidenced-Based Practice Series

If that isn’t enough, NursingCenter also hosts the JBI tools on our Evidenced-Based Practice Network. The network offers peer-reviewed resources aimed to integrate evidence into practice in an effort to support clinical decision making. The JBI tools include JOURNAL CLUB*, where you can gain access to journals for evidence-based practice targeted to your specialty; SUMARI* a premier review software package helping health professionals conduct systematic reviews, TAP*; which allows you to analyze small qualitative datasets; and CAN-IMPLEMENT*, which tailors your clinical practice guidelines for local use.

NursingCenter is your one-stop shop for all things JBI. Be sure to check back regularly for new JBI content. 
Posted: 6/13/2016 10:49:54 AM by Cara Gavin | with 2 comments

Categories: Continuing EducationEvidence-Based Practice


Red meat and cancer: the beef on beef

Over the past week, several people have asked me about recent news related to red meat and processed meat causing cancer. Could it be true? Is it really as dangerous as smoking? Do I need to stop using my grill?

While the association between red meat and cancer is not new information, a recent systematic review presented at the International Agency for Research on Cancer (IARC) has both categorized the risk and reignited the conversation among healthcare professionals and the public. Here are some related definitions and a summary of the results that the researchers shared:
  • Red meat is unprocessed mammalian muscle meat, including beef, veal, pork, lamb, mutton, horse, or goat meat. 
  • Processed meat has been transformed through salting, curing, fermentation, smoking, or other processes.
  • The group looked at “more than 800 epidemiological studies that investigated the association of cancer with consumption of red meat or processed meat in many countries, from several continents, with diverse ethnicities and diets.” (You can read more specifics on the studies in The Lancet Oncology. Free registration on the site is required). 
  • Overall conclusions: 

“Overall, the Working Group classified consumption of processed meat as “carcinogenic to humans” (Group 1) on the basis of sufficient evidence for colorectal cancer. Additionally, a positive association with the consumption of processed meat was found for stomach cancer.”

“The Working Group classified consumption of red meat as “probably carcinogenic to humans” (Group 2A). In making this evaluation, the Working Group took into consideration all the relevant data, including the substantial epidemiological data showing a positive association between consumption of red meat and colorectal cancer and the strong mechanistic evidence. Consumption of red meat was also positively associated with pancreatic and with prostate cancer.”

So what does this mean? 

The evidence groups assigned by IARC refer to how likely a particular cancer risk is to actually cause cancer. Group 1 carcinogens (processed meat, smoking, alcohol) are classified as definite causes; Group 2a carcinogens (red meat, shift work) are classified as probable causes. But remember, it’s all about how confident the IARC is that something causes cancer, not how much cancer results.

This analogy shared by Cancer Research UK makes this a little easier to understand:  

“To take an analogy, think of banana skins. They definitely can cause accidents – but in practice this doesn’t happen very often (unless you work in a banana factory). And the sort of harm you can come to from slipping on a banana skin isn’t generally as severe as, say, being in a car accident. 

But under a hazard identification system like IARC’s, ‘banana skins’ and ‘cars’ would come under the same category – they both definitely do cause accidents.”

So while processed meat and tobacco are in the same Group 1 category – known to cause cancer – the risk of cancer from tobacco use is much higher than the risk of cancer related to eating processed meat. (You can see some great infographics here). 

Am I going to stop eating red meat?

No, I’ll still enjoy the occasional hamburger or hot dog. When it comes to meat, I already opt for chicken, turkey or fish more often than red meat, so I do feel pretty good about the balance in my current diet. And of course, I try to get plenty of fruits and vegetables too!

Has this recent report influenced you to make any changes to your diet? How do you answer patients (and friends and family) when they ask you “Should I stop eating meat?”
References 
Bouvard, V., Loomis, D., Guyton, K., Grosse, Y., Ghissassi, F., Benbrahim-Tallaa, L., . . . Straif, K. (2015). Carcinogenicity of consumption of red and processed meat. The Lancet Oncology.
Dunlop, C. (2015, October 26). Processed meat and cancer - what you need to know. Retrieved from Cancer Research UK: http://scienceblog.cancerresearchuk.org/2015/10/26/processed-meat-and-cancer-what-you-need-to-know/ 
World Health Organization. (2015, October 29). Links between processed meat and colorectal cancer. Retrieved from World Health Organization: http://www.who.int/mediacentre/news/statements/2015/processed-meat-cancer/en/
World Health Organization. (2015, October). Q&A on the carcinogenicity of the consumption of red meat and processed meat. Retrieved from World Health Organization: http://www.who.int/features/qa/cancer-red-meat/en/


     

 

Posted: 11/4/2015 5:06:13 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice


NursingCenter’s “Specialty Sites”

Are you familiar with NursingCenter’s specialty sites? In the past few years, NursingCenter has launched two specialty sites, the Evidence Based Practice Network and the Skin Care Network. Both sites feature targeted, in-depth content and each have their own unique features and products. Let’s take a quick glance to learn more about these sites.

The Skin Care Network

The Skin Care Network was launched in 2011 by the clinical and editorial team of Lippincott's NursingCenter.com in collaboration with the Dermatology Nurses' Association and the American Society of Plastic Surgical Nurses. The goal is to share all the dermatology and skin care content from Lippincott's vast collection of nursing journals and keep you up-to-date with the latest research, news, and information your patients may be reading or hearing about in the media. 

Take a look at some of our features: 

News
Discover the latest research findings and evidence-based practice recommendations, as well as links to related mainstream media items.

Tools & Resources
Organized by clinical topic, pages feature all dermatology and skin care continuing education opportunities and patient education tools.

Society Partners
Learn more about the Dermatology Nurses' Association and the American Society of Plastic Surgical Nurses.

Skin Care Insider eNewsletter
Sign up for our free monthly eNewsletter that offers you the latest on skin care!

Social Media
Look for The Skin Care Network on Facebook and Twitter.

The Evidence-Based Practice Network

Lippincott’s Evidence-Based Practice Network is an online resource powered by LWW and the Joanna Briggs Institute (JBI), which promotes and supports the synthesis and transfer of evidence-based practice information to healthcare professionals. The network offers peer-reviewed resources aimed to integrate evidence into practice in an effort to support clinical decision making. 

Here are some network highlights: 

JBI Tools

JOURNAL CLUB*
Here, you gain access to journals for evidence-based practice targeted to your specialty, as well as the opportunity to share information and ideas with other professionals.

SUMARI*
This premier review software package helps health professionals conduct systematic reviews of evidence of feasibility, appropriateness, meaningfulness, and effectiveness of health intervention.

TAP*
Analyze small qualitative datasets following a three-step process of entering data, categorizing data, and building themes. 

CAN-IMPLEMENT*
Tailor your clinical practice guidelines for local use with this JBI tool. 

JBI Library
Subscribe and gain access to JBI’s vast collection of evidence-based resources. 

JBI Continuing Education
Discover JBI’s continuing education resources, as well as their evidence-based practice series. 

EBP Insider eNewsletter
Sign up to receive our free monthly eNewsletter!

Social Media
Follow The EBP Network on Facebook and Twitter

Posted: 3/19/2014 4:49:19 PM by Cara Gavin | with 2 comments

Categories: Evidence-Based Practice


Defining Features of a Systematic Review

Today, I listened in on the Ovid Webcast, Beyond the Search: Maximizing the Quality of Systematic Reviews. Dr. Edoardo Aromataris, PhD, Director of Synthesis Science at the Joanna Briggs Institute in Adelaide, Australia and Dr. Craig Lockwood, PhD, RN, BN, GDip, ClinNurs, MNSc, Director of Translation Science at the Joanna Briggs Institute in Adelaide, Australia successfully gave me a better understanding of systematic reviews.

Whether you are reading journal articles, completing educational requirements, or performing research yourself, it is important to be aware of the components of a comprehensive systematic review. Why? The presence of specific defining features indicates a high level of rigor in the research which helps ensure that the review is reproducible (same results) and transparent (same conclusion).

So what are these defining features of a systematic review?
  1. A prespecified question 
  2. Defined inclusion and exclusion criteria
  3. An extensive literature search that includes international research
  4. Selection of studies based on the inclusion criteria
  5. Assessment of the quality of the included studies
  6. Extraction of the data
  7. Analysis of the data
  8. Presentation of the results
  9. Interpretation of the results
We are fortunate that these two experts also co-authored books in the Lippincott-Joanna Briggs Institute Synthesis Science in Healthcare Book Series. It was a pleasure learning from them today! Also, for those of you performing systematic reviews, remember to check out the JBI tools on the Evidence-Based Practice Network to help you appraise and synthesize the evidence.
References:
Egger, M., Smith, G., & Altman, D. (2001). Systematic Reviews in Health Care: Meta-analysis in context. London: BMJ Publishing Group.
Glasziou, P., & et al. (2004). Systematic Reviews in Health Care: A Practical Guide. Cambridge: Cambridge University Press.
 
Posted: 3/12/2013 6:43:42 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice


Time to get dressed! The research on nursing uniforms

The debate over standardization of nursing uniforms is well-documented, however, the existence of rigorous, well-designed studies is lacking. In the latest issue of JONA, Journal of Nursing Administration, an integrative review examining the professional appearance of RNs examines the evidence. While the strength of the evidence is low, it is essential for us to recognize the importance of patients being able to identify us as nurses and to understand how our attire impacts the public’s perception of our knowledge and skills.

Seven studies were included in this review and a nice table comparing each of the studies can be found in this supplemental digital content. One study found that among nurses, students, and patients, solid color scrubs reflect more skills and knowledge than print scrubs or T-shirt tops. Another study, which looked at uniform color preference among patients, found blue or white to be most preferred, while red was least preferred. Take a close look at this table to learn more about how both patients and nurses feel that uniform and general appearance impact perception. It’s pretty interesting.
Is there a standard uniform for nursing staff where you work? 
Reference: 
Cassidy, C., Del Guidice, M., Hatfield, L., Pearce, M., Polomano, R., Samoyan, J. (2013). The Professional Appearance of Registered Nurses: An Integrative Review of Peer-Refereed Studies. JONA, Journal of Nursing Administration, 42(2). 





 
Posted: 2/10/2013 11:11:46 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Evidence-Based Practice


Using a journal club to increase EBP knowledge and implementation

We know that evidence-based practice (EBP) leads to improved patient outcomes. Yet it is also known that nurses identify barriers to implementing evidence-based practice, such as lack of knowledge, support, time, and authority to change practice (O'Nan, 2011). Change can be difficult, but as nurses it is our responsibility to our patients and our profession to develop and implement activities that promote evidence-based practice. One such activity that can help us overcome barriers and incorporate research findings into practice is a journal club. A journal club can be described as “the sharing of contemporary knowledge and appraising the value of that knowledge for applications in clinical practice” (Duffy, Elpers, Hobbs, Niemeyer-Hacket, & Thompson, 2011). 

What are the benefits of a journal club?
  • Sharing knowledge of current clinical research 
  • Facilitating the learning process
  • Enhancing literature critique and appraisal skills 
  • Encouraging interaction and dialogue with other nurses
  • Encouraging research utilization
  • Promoting team building 
  • Promoting EBP in a cost-effective manner
What are the steps for starting a journal club?
  • Decide if the journal club will be unit-based or hospital-wide.
  • Gain the support of unit managers or senior nursing administration. Be prepared to discuss the benefits, objectives, scope of work, timetable, and key stakeholders (Chabot, et al., 2011).
  • Determine meeting schedule and length.
  • Identify a leader/facilitator.
  • Identify the topic of interest.
  • Select and disseminate article(s).
  • Hold meeting and discuss the topic/appraise the evidence.
  • Determine if further research or action is needed.
You can learn more by reading the articles referenced below. There are great ideas to help you get started and also to determine the best schedule for your group, the roles and responsibilities of the facilitator and members, and how to evaluate your group’s success. Also, consider the use of an online journal club or use of the tools available from the Joanna Briggs Institute to help you appraise the evidence. Good luck!
References
Chabot, J., Conners, S., DeNigris, J., Dunn, R., Panzera, A., & Patel, P. (2011). Evidence-Based Practice and a Nursing Journal Club: An Equation for Positive Patient Outcomes and Nursing Empowerment. Journal for Nurses in Staff Development, 227-230. 
Duffy, J., Elpers, S., Hobbs, T., Niemeyer-Hacket, N., & Thompson, D. (2011). Evidence-Based Nursing Leadership: Evaluation of a Joint Academic-Service Journal Club. JONA: Journal of Nursing Administration, 422-427.
O'Nan, C. (2011). The Effect of a Journal Club on Perceived Barriers to the Utilization of Nursing Research in a Practice Setting. Journal for Nurses in Staff Development, 160-164.
Posted: 11/29/2012 11:27:25 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice


​Self-Care and Lymphedema

My first preceptor was a nursing assistant who had been treated for breast cancer several years prior to my orientation. While I didn’t know the extent of her disease or treatment, I can still remember the tight wrap that she wore on her left arm and the arm exercises that she would do whenever we had a little “down time” on the unit. 

I couldn’t help but think of this woman, who helped me get started on my path into nursing, when I read Self-Management of Lymphedema: A Systematic Review of the Literature From 2004 to 2011, published in the August issue of Nursing Research. Self-management has long been recommended for the treatment of lymphedema as this chronic condition cannot be cured medically or surgically; lifetime self-management is necessary to control swelling exacerbations, prevent infections, and manage other lymphedema-associated symptoms, including reduced activity and fatigue.

Sixteen articles met the inclusion criteria for this systematic review and based on the review, the authors identified ten categories of self-management:
* Advanced pneumatic compression devices
* Aromatherapy
* Compression garments
* Full-body exercise
* Infection management
* Phase 2 complete decongestive therapy (includes self-administered manual lymphatic drainage [MLD], compression garments, bandaging, exercise, and skin care)
* Simple MLD
* Skin care
* Self-monitoring
* Weight reduction

This review found that full-body exercise and Phase 2 CDT are likely to be effective self-management techniques for lymphedema, however, randomized control trials supporting Phase 2 CDT are lacking. Effectiveness was not established for advanced pneumatic compression, compression garments, full-body exercise, self-monitoring, skin care, simple MLD, and weight reduction as stand-alone therapies. Also, based on the evidence, aromatherapy was deemed effectiveness unlikely and should not be recommended as a self-care technique. 

Unfortunately the evidence does not provide much guidance for self-management recommendations for lymphedema. Further research is indicated, yet in the meantime, a thorough assessment of each individual patient’s symptoms and the availability of resources should be used to guide the plan of care.
Reference: 
Armer, J. M., Cormier, J.N., Fu, M.R., Ridner, S.H., Stewart, B.R., Wanchai, A. (2012). Self-Management of Lymphedema: A Systematic Review of the Literature From 2004 to 2011. Nursing Research, 61 (4). 
Posted: 8/3/2012 2:18:59 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice


Presenting the Evidence: Poster Presentations

Last week I had the pleasure of attending Nursing2012 Symposium in Orlando, Florida. One of the sessions, titled Faculty-Guided Poster Tour: Ask the Experts, was a highlight for me. This session was exactly what the title implies; an informal tour of the posters being presented at the conference. Three experts – Frank Myers, MA, CIC; Cheryl Dumont, PhD, RN; and Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC – led the session which was held right in the exhibit hall where the posters were displayed. Frank Myers who critiqued each presentation first, initially broke the ice by sharing that he’s taken about 15 research courses throughout his career and education and asked “What does that make me?” While I thought “an expert,” “amazing,” and “impressive,” he answered for us all by saying “Boring!” It certainly was a fun and interactive session!

The leaders shared their reactions and feedback on 6 of the posters. They pointed out key features of the posters themselves as well as the research being presented. It was helpful to get tips about what a poster should look like, what the elements should be, and a little bit more of the intricacies of research and evidence. Here are some of the things that I learned and I hope that you find them useful too!

The poster should…
•    Be visually attractive.
•    Be about 1/3 pictures and/or graphs.
•    Have about 20% white space.
•    Be legible from 3-4 feet away.
•    Be organized so that the content flows in a logical manner.
•    Include your references.

Regarding the research…
•    Be clear about what you are testing.
•    Make sure you have a good reason to do the research.
•    Get approval from the Internal Review Board (IRB) if needed. 
•    Understand the difference between an observation study and an intervention study.
•    When using graphs to show your data, note the intervention period on the graph.
•    When considering endpoints, pay attention to other fields or disciplines. 
•    Know what the “popcorn effect” is – remember that during the first weeks of an intervention, people are more likely to like it and perform it.
•    Use rate (for example, amount/1000 patient days) rather than just a number when reporting results.
•    Understand the difference between statistical significance and clinical significance. 
•    Compare mean and median to balance outliers. It’s generally okay to discard outliers when they are 2 standard deviations from median or when you disclose that you’ve done so (ask yourself if patient who is an outlier matches your patient population). 
•    With regard to sample size, it should never be smaller than 30 and more than 1,500 won’t impact your findings. The more covariants you have, the bigger your sample size needs to be. 
•    Anytime something “jumps” out, such as a peak or downward trend, explain it.

Other tips…
•    Spell out acronyms with first use.
•    Remember your audience; not everyone is an expert in statistical analysis.
•    Don’t cut and paste from statistical analysis programs; create new tables and graphs.
•    Supplement your poster with print copies and also copies of any tools you developed for the intervention.
•    Include information about the financial impact of your intervention to “sell” it to administration. 
•    Be savvy with terminology – use “cost avoidance” rather than “cost savings.”

Poster presentations can be used as a “stepping stone” to publication. Consider turning your research into a poster and presenting it at an appropriate conference. It’s a wonderful way to get feedback from your peers which you can then incorporate into a manuscript. 
Posted: 5/3/2012 11:57:47 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice


Comfort in terminal extubation: Minimal evidence, maximal need

Studying the dying process and terminal extubation in particular, is clearly a challenge. Are the measures we choose even relevant to the person in the bed? We may never know. Nevertheless, some brave souls have attempted to offer their best effort on it. What they mostly do is retrospectively review the chart for processes of care and trends of results. This amounts to little more than consensus of expert opinion but is the best most have been able to achieve to date.

A few trends became obvious as one team reviewed this literature and offered their own local experience. Some of this is just plain common sense. For example, if you don’t need to use devices to maintain patient comfort or resting safety, then don’t. If you don’t need to start an intravenous to give medications, then don’t. Use alternate routes. We have oral morphine (Roxanol) and we can use atropine eye drops under the tongue for secretions. Never stop comfort measures already in place, such as benzodiazepines (Kompanje, 2008). Truog et al. (2008) reminded us all that the goal is to support dignity and comfort, providing quiet, comfortable spaces for the patient and family, absent the trappings of technology, full of human caring. Turn off the alarms and monitors.

Experts argue about the speed of withdrawal of the endo-tracheal tube, but are clear that there are circumstances where it is not appropriate to remove it: large volume of secretions and swollen tongue , for example (Campbell, 2007). Truog et al. (2008) cited the absence of evidence governing this subject. They further noted that rapid withdrawal may cause dyspnea and related discomfort.

Fear of causing a premature death via opioids paralyzes some. Mazer et al. (2011) found that the mean dose of morphine just before death was about 10 mg. During the last hour of life each 1 mg/hour increment of morphine infused was associated with a delay of death by 7.9 minutes. The authors encouraged practitioners to reduce their concern for premature death and act purely on the patient’s assessed needs for comfort.

Truog and colleagues (2008) did their best to summarize care recommendations in a consensus statement by the American College of Critical Care Medicine. This was published in Critical Care Medicine, in 2008. Authors included nurses and physicians knowledgeable in the field. Although many hope this will change as time goes on, around 20% of all deaths in the United States occur in ICUs. Clinicians need to apply the same vigor to dignity and comfort preservation as they do to life saving.

References
Kompanje, E.O., Van der Hoven, B., & Bakker, J. (2008) Anticipation of distress after discontinuation of mechanical ventilation in the ICU at end of life. Intensive Care Medicine, 34, 1593-1599.

Mazer, M. A. (2011). The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit. Journal of Pain and Symptom Management, 42(1), 44-51.

Truog, RD et. al. (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine. Critical Care Medicine. 36(3), 953-961.

Submitted by:
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System

www.meridianiebc.com

 
Posted: 4/16/2012 7:47:38 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice


A Lesson from the Evidence: Replacing Emergently Placed Peripheral IVs

When a patient has a peripheral line placed in an emergency, whether it is out in the field or in an acute care setting, the intravenous infusion device is discontinued and replaced as soon as possible and certainly within 48 hours (CDC, 2002). This policy from the Centers for Disease Control  and Prevention has been the mainstay of our practice for many years, but is it still best practice? The Infusion Nurses Society thinks differently and recommends that without signs of catheter-related complications, pre-hospital peripheral catheters should not be routinely replaced (Mermel, Farr, & Sheretz. 2001).

A study published in the Journal of Trauma Nursing, Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous Catheter, examined this issue.Their study was a descriptive, archival, retrospective study that reviewed 365 trauma patients, over the age of 17 years, who were admited to an urban level 1 trauma center. The results demonstrated that less than 1% of the patients had complications related to a prehospital peripheral intravenous catheter being left in place longer than 48 hours (Clemin, Heldt, & Jones, et. al., 2012).

What are the implications for practice? Although one study should not change practice, there is evidence in the literature that the current policy needs to be further investigated through research and revised. I encourage all of you to base your practice on evidence and recognize that evidence is not stationary, it evolves every day. What was evidence-based practice 10 years ago, may not be best practice today.

References:
Centers for Diseas control and Prevention, 2002.
Guidelines for the prevention of intravascular catheter-related infections. MMWR,  (5)1, 1-29.

Clemin, Heldt, & Jones, et. al., 2012.
Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous CathetersJournal of Trauma Nursing, (19)1, 46-49.

Mermel, L., Farr, B., & Sherentz, R. et. al., 2001.
Guidelines for the management of intravascular catheter-related infections
. Journal of Infusion Nursing, (24)3, 180-205.

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies
Posted: 4/9/2012 7:28:08 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice


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