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Nurses' Recognition of Delirium and Its Symptoms
Comparison of Nurse and Researcher Ratings
Sharon K. Inouye, MD, MPH;
Marquis D. Foreman, PhD, RN;
Lorraine C. Mion, PhD, RN;
Karol H. Katz, MS;
Leo M. Cooney, Jr, MD
Arch Intern Med. 2001;161:2467-2473.
ABSTRACT
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Background Nurses play a key role in recognition of delirium, yet delirium is often
unrecognized by nurses. Our goals were to compare nurse ratings for delirium
using the Confusion Assessment Method based on routine clinical observations
with researcher ratings based on cognitive testing and to identify factors
associated with underrecognition by nurses.
Methods In a prospective study, 797 patients 70 years and older underwent 2721
paired delirium ratings by nurses and researchers. Patient-related factors
associated with underrecognition of delirium by nurses were examined.
Results Delirium occurred in 239 (9%) of 2721 observations or 131 (16%) of 797
patients. Nurses identified delirium in only 19% of observations and 31% of
patients compared with researchers. Sensitivities of nurses' ratings for delirium
and its key features were generally low (15%-31%); however, specificities
were high (91%-99%). Nearly all disagreements between nurse and researcher
ratings were because of underrecognition of delirium by the nurses. Four independent
risk factors for underrecognition by nurses were identified: hypoactive delirium
(adjusted odds ratio [OR], 7.4; 95% confidence interval [CI], 4.2-12.9), age
80 years and older (OR, 2.8; 95% CI, 1.7-4.7), vision impairment (OR, 2.2;
95% CI, 1.2-4.0), and dementia (OR, 2.1; 95% CI, 1.2-3.7). The risk for underrecognition
by nurses increased with the number of risk factors present from 2% (0 risk
factors) to 6% (1 risk factor), 15% (2 risk factors), and 44% (3 or 4 risk
factors; Ptrend<.001). Patients with
3 or 4 risk factors had a 20-fold risk for underrecognition of delirium by
nurses.
Conclusions Nurses often missed delirium when present, but rarely identified delirium
when absent. Recognition of delirium can be enhanced with education of nurses
in delirium features, cognitive assessment, and factors associated with poor
recognition.
INTRODUCTION
DELIRIUM IS a common and serious problem for hospitalized older patients
and is associated with substantial morbidity and mortality rates.1 Occurring in 14% to 56% of hospitalized older patients,
delirium represents the most frequent complication of hospitalization for
this group.2-3 Despite its importance,
delirium is often underrecognized in the hospital setting. Previous studies4-7 have
shown that clinicians caring for the patient do not recognize delirium in
up to two thirds of cases. Whereas many barriers to the recognition of delirium
have been hypothesized,1 patient-related factors
contributing to underrecognition have not been directly examined.
Nurses, who spend more time at the bedside than physicians, play a crucial
role in the recognition of delirium. Because nurses have frequent and continuous
contact with patients, they can better observe fluctuations in attention,
level of consciousness, and cognitive functioning.8-9
As a result, the observations made by nurses are critical for the early detection
of delirium symptoms10-11 and
for the continuous monitoring of these symptoms that is essential to follow
the patient's clinical course.12 With training
and supervision, delirium symptoms can be monitored effectively by nurses.12
The Confusion Assessment Method (CAM) is a simple, standardized instrument
designed to assist with detection of delirium.13
The CAM is widely used in both clinical and research settings and has been
translated into at least 5 languages. In the initial validation study, the
CAM instrument was scored by geriatricians and trained research nurses after
cognitive assessment with the Mini-Mental State Examination (MMSE). When validated
against the ratings of geriatric psychiatrists, the CAM had sensitivity of
94% to 100%, specificity of 90% to 95%, and high interobserver reliability.
However, the question remained of how the CAM would perform when rated by
nurses during routine clinical care—without formal cognitive assessment.
Such evaluation would offer important insight into the process of recognition
of delirium in the real-world hospital setting. This evaluation provides an
opportunity to examine factors that might contribute to underrecognition of
delirium by nurses.
The overall goal of this study was to compare recognition of delirium
by nurses based on nursing observations made during routine clinical care
(without formal cognitive testing) when interviewed by trained researchers
using the CAM compared with concurrent ratings made by the researchers after
formal cognitive assessment. The specific objectives were to compare nurse
and researcher ratings for delirium (overall) and for specific delirium features
using the CAM and to identify risk factors associated with underrecognition
of delirium by nurses.
PATIENTS AND METHODS
STUDY POPULATION
This study was performed as part of a larger clinical epidemiological
investigation of hospitalized older patients.14-16
Potential participants were 1587 consecutive patients 70 years and older admitted
to the medicine and surgery (non–intensive care) floors at Yale–New
Haven Hospital, New Haven, Conn, between November 6, 1989, and July 31, 1991.
Yale–New Haven Hospital is an 800-bed urban teaching facility with 200
medical and 190 surgical beds serving a large community and a referral population.
The community population served represents a culturally diverse group in terms
of ethnicity, educational level, socioeconomic status, and country of origin.
Patients were excluded if they could not be interviewed for any reason, ie,
intubation, coma, severe aphasia, or terminal condition (n = 265 [17%]); if
they were discharged within 48 hours (n = 232 [15%]); if they or their physicians
declined participation (n = 134 [8%]); or if they had been enrolled in the
study during a previous hospital admission (n = 142 [9%]). Of 814 enrolled
participants, 7 (1%) were excluded from the present study because of incomplete
interviews and 10 (1%) because of incomplete CAM information. Thus, the final
sample included 797 participants.
CLINICAL EVALUATION
Trained clinical researchers conducted standardized interviews with
the participants and their primary nurses from study entry until hospital
discharge. The baseline patient interview, completed within 48 hours of admission,
included demographic information (eg, age, sex, race, educational level, and
marital status), current living situation, self-reported activities of daily
living,17 MMSE score,18
standard near-vision (Jaeger type) and hearing (whisper) tests,19
and the CAM rating for delirium.13 The baseline
nurse interview included the nurse's rating of the patient's overall mental
status (confused vs not confused), any acute change or fluctuation in mental
status (yes vs no), any evidence of delirium (present vs absent), and any
evidence (present vs absent) of each of the individual items of the CAM for
delirium (ie, inattention, disorganized thinking, altered level of consciousness,
disorientation, memory problems, or inappropriate behavior). Examples and
prompts for each delirium feature were provided to assist the nurses. To avoid
potential bias, the order of nurse and patient interviews was alternated,
ie, nurses were interviewed first in half of the cases and patients were interviewed
first in the other half. The medical record was abstracted at baseline for
data required to complete an APACHE (Acute Physiology and Chronic Health Evaluation)
II score.20 A family member or caregiver was
interviewed at baseline to complete the modified Blessed Dementia Rating Scale.21-22
Thereafter, the clinical researchers interviewed the patients and their
nurses every other day until hospital discharge. Patient interviews included
MMSE and CAM ratings. Nurse interviews included ratings of overall mental
status and evidence of delirium or specific delirium features.
All data were obtained using standardized instruments. The clinical
researchers were masked to the research questions and hypotheses. Informed
consent was obtained from participants or, for those with substantial cognitive
impairment, from the closest relative or legal guardian. The study was approved
by the institutional review board of Yale University School of Medicine, New
Haven.
COMPARISON OF NURSE AND RESEARCHER RATINGS
Nurse ratings of delirium (overall and individual CAM features), based
on their observations during routine clinical care without formal cognitive
testing, were compared with clinical researcher ratings. For determination
of sensitivity and specificity, researcher ratings, which were based on formal
cognitive assessment including the MMSE and which were validated in a previous
study,13 were used as the reference standard.
Because multiple paired observations between nurse and researcher were available
for each patient, the "best case" comparison was selected as the pair with
the best observed agreement between researcher and nurse ratings to provide
1 rating per patient. Conversely, the "worst case" comparison was selected
as the pair with the worst observed agreement between researcher and nurse
ratings for that patient.
OUTCOMES
The primary outcomes were sensitivity, specificity, and concordance
( statistic) comparing nurse and researcher ratings of delirium. Underrecognition
of delirium by nurses was used as a secondary outcome for risk factor analyses.
DEFINITIONS OF STUDY VARIABLES
Delirium was defined by fulfillment of the CAM criteria,13
which consisted of acute onset and a fluctuating course of symptoms, inattention,
and either disorganized thinking or altered level of consciousness. Inattention
was defined as the patient's having difficulty focusing attention, such as
being distracted easily, or having difficulty keeping track of what was being
said. Disorganized thinking was defined as the patient's speech being disorganized
or incoherent, such as rambling or irrelevant conversation, unclear or illogical
flow of ideas, or unpredictable switching from subject to subject. Altered
level of consciousness was defined as a level of consciousness other than
normal (alert), such as vigilant (hyperalert or overly sensitive to environmental
stimuli), lethargic (drowsy but easily aroused), or stupor (difficult to arouse).
Disorientation was defined as the patient's demonstrating poor orientation
to time or place, such as thinking that he or she was somewhere other than
the hospital, using the wrong bed, or misjudging the time of day. Memory impairment
was defined as the patient's demonstrating memory problems, such as the inability
to remember events in the hospital or difficulty remembering instructions.
Inappropriate behavior was defined as actions considered unsafe or disruptive,
such as loud vocalizations, wandering, climbing over bedrails, and physical
or verbal aggressiveness.
Patient-related variables associated with underrecognition of delirium
by nurses were evaluated. These investigations were performed to determine
whether characteristics of the patients, or of the type of delirium, might
have made identification of delirium more difficult. Baseline variables examined
included patient characteristics such as age, sex, race, educational level,
hearing and/or vision impairment, functional disability, cognitive impairment,
and illness severity. Cutoff points for variables were selected a priori and
based on clinically relevant values or previously published studies. Any activity
of daily living impairment was defined as needing physical assistance with
at least 1 of 7 basic care skills (ie, feeding, bathing, grooming, dressing,
toileting, transferring, or walking) by patient self-report referent to 2
weeks before hospital admission; this cutoff point has been used previously.14-15 Hearing impairment was defined as
correctly hearing 6 or fewer of 12 numbers with both ears on the whisper test.23 Vision impairment was defined as corrected binocular
near vision worse than 20/70 on the standard bedside Jaeger test.23 Delirium risk group was defined using a previously
developed predictive model14 based on 4 risk
factors for delirium: vision impairment, severe illness, cognitive impairment,
and a high serum urea nitrogen to creatinine ratio. High delirium risk was
defined as the presence of 3 or 4 of these risk factors at baseline. Dementia
was categorized according to the definition used in previous studies16, 24 as (1) a modified Blessed Dementia
Rating Scale score greater than 4 or (2) a modified Blessed Dementia Rating
Scale score greater than 2 and an MMSE score less than 20 and duration of
cognitive symptoms of at least 6 months. To indicate high severity of illness,
the cutoff point of greater than 16 was used for the APACHE II index.14, 25 One postbaseline variable, the presence
of hypoactive delirium, was examined for its association with underrecognition
by nurses. Hypoactive delirium was defined as the presence of delirium with
psychomotor retardation, characterized by an unusually decreased level of
motor activity, such as sluggishness, staring into space, staying in one position
for a long time, or moving extremely slowly. Although different pathogenic
mechanisms for delirium (eg, infection, medications, and metabolic derangements)
may have the potential to affect recognition of delirium, exploration of these
myriad factors was beyond the scope of the present study.
STATISTICAL ANALYSES
Sensitivity, specificity, and 95% confidence intervals for sensitivity
and specificity were calculated using standard formulas.26-27
The coefficient for concordance was used as the index of agreement
exceeding chance, and the 95% confidence interval for was calculated
using standard approaches. Kappa values greater than 0.75 indicate excellent
agreement beyond chance, values from 0.40 to 0.75 indicate fair to good agreement
beyond chance, and values less than 0.40 indicate poor agreement beyond chance.28-29 For these analyses, nurse ratings
were compared with researcher ratings, the reference standard. First, nurse
ratings for delirium were compared with researcher ratings for all observations.
Subsequently, the best case and worst case (see the "Comparison of Nurse and
Researcher Ratings" subsection) observations were compared to provide 1 observation
per patient. Finally, the individual CAM delirium symptoms were compared to
evaluate whether specific criteria were consistently rated differently by
nurses compared with researchers.
In bivariate analyses, rates of delirium not being recognized by nurses
were calculated for the best case comparison when each risk factor was present
or absent. Crude odds ratios and associated 95% confidence intervals were
calculated. Subsequently, variables with odds ratios greater than 2.0 and
clinical relevance were selected for evaluation in multiple logistic regression
analysis. The final risk factors were selected using a stepwise algorithm
with backward elimination (P<.10 to remove a variable).
To avoid redundancy, vision impairment was selected for inclusion from among
several sensory impairment variables because it had the strongest bivariate
association with underrecognition by nurses. Adjusted odds ratios and 95%
confidence intervals were calculated for the final independent risk factors
from the parameter estimates and SEs.
A risk stratification system was developed by adding 1 point for each
of the final risk factors present for each patient. The Mantel-Haenszel  2 trend test was used to compare rates of underrecognition by nurses
between risk groups.
All statistical tests were 2-tailed, and P<.05
was considered statistically significant. All analyses were performed using
the SAS statistical program (version 6.10; SAS Institute Inc, Cary, NC).
RESULTS
Baseline characteristics of the study population of 797 patients are
shown in Table 1. Delirium occurred
in 239 (9%) of 2721 observations or 131 (16%) of 797 patients. This population
represents an acutely ill older population (mean age, 78.4 years) of hospitalized
medical and surgical patients. The degree of cognitive and functional impairment
at baseline was substantial, with 40% of patients having an MMSE score less
than 24 and 60% having at least 1 activity of daily living impairment at baseline.
Overall, 2721 paired observations by nurses and researchers were made in the
797 patients, for a mean ± SD of 3.4 ± 2.1 observations per
patient. The specific nurse often varied between observations on the same
patient.
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Table 1. Baseline Characteristics of the Study Population
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Table 2 presents the comparison
of nurse and researcher delirium ratings for all paired observations and for
best and worst case comparisons. Researchers found evidence of delirium in
239 of 2721 assessments; nurses identified delirium in only 46 of these observations
(19.3%). Of 131 patients who developed delirium, nurses identified this condition
in only 40 (30.5%) using best case comparisons. Thus, the sensitivity of nurse
ratings for delirium using the CAM criteria was generally low compared with
that of researcher ratings (19.3% overall, 30.5% for best case, and 13.7%
for worst case), indicating that most cases of delirium were not identified
by nurses. The specificity of nurse ratings for delirium, however, was high
compared with that of researcher ratings (95.8% overall, 99.4% for best case,
and 90.8% for worst case), indicating that nurses did not overidentify delirium
(ie, identify a patient as delirious when he or she was not). Agreement beyond
chance was generally poor ( = 0.18 overall, 0.40 for best case, and
0.05 for worst case).
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Table 2. Comparison of Nurse and Researcher Delirium Ratings*
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Table 3 presents the best
case comparison of nurse and researcher ratings of individual CAM features.
For the 3 key delirium features used in the CAM algorithm—inattention,
disorganized thinking, and altered level of consciousness—the sensitivities
ranged from 15% to 26%, indicating that these features were often missed.
For example, nurses identified inattention only 25 (15%) of the 163 times
that this feature was present. Disorganized thinking was noted by nurses in
only 20 (26%) of 76 observations where present, and altered level of consciousness
was noted in only 18 (15%) of 121 positive observations. However, the high
specificities (99% for all) indicate that these features were rarely identified
by nurses when absent. Kappa statistics ranged from 0.22 to 0.37, indicating
poor agreement exceeding chance. Disorientation and memory impairment were
recognized in only 30 (7%) of 436 and 27 (4%) of 607 cases, respectively,
when present, with statistics ranging from 0.02 to 0.06, indicating
extremely poor agreement. Inappropriate behavior was better recognized by
nurses, with a sensitivity of 47% and of 0.36. Notably, specificity
rates remained high for all features. Nearly all disagreements in ratings
between nurses and researchers were because of underrecognition of delirium
and its symptoms by nurses when they were present.
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Table 3. Best Case Comparison of Nurse and Researcher Ratings of Individual
CAM Features in 797 Patients*
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Potential variables associated with underrecognition of delirium by
nurses are presented in Table 4.
Of 14 variables considered, 6 were selected on the basis of clinical relevance
and quantitative significance (odds ratio >2.0): age 80 years and older, any
impairment in activities of daily living, vision impairment, high baseline
delirium risk, dementia, and presence of the hypoactive form of delirium.
After multivariable analysis, 4 final risk factors were selected (Table 5): hypoactive delirium, age 80 years
and older, vision impairment, and dementia. Patients with hypoactive delirium
demonstrated a 7-fold risk of underrecognition by nurses.
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Table 4. Potential Variables Associated With Underrecognition of Delirium
by Nurses in 797 Patients*
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Table 5. Final Independent Risk Factors Associated With Underrecognition
of Delirium by Nurses in 760 Patients*
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To demonstrate the cumulative effect of these risk factors, a risk stratification
system was developed by summing the number of risk factors present in each
patient (Figure 1). With no risk
factors present, the rate of not being recognized by nurses as having delirium
was 2%, increasing to 44% when 3 or 4 risk factors were present. As shown
in Figure 1, patients who were older,
visually impaired, demented, and with hypoactive delirium were 20-fold times
less likely to be recognized by nurses as having delirium than those who did
not have these risk factors.
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Risk for underrecognition of delirium by nurses by number of risk
factors. The rates of underrecognition of delirium by nurses and associated
relative risks are shown by number of risk factors present per patient (Mantel-Haenszel 2 [trend] = 91.8; P<.001). Thirty-seven
patients were excluded from these analyses because of missing data on risk
factors as follows: vision missing in 14, dementia in 14, both vision and
dementia in 2, and hypoactive delirium rating in 7.
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COMMENT
Nurses are key to the early recognition of delirium, yet this study
showed that when the CAM was rated by untrained nurses as part of routine
clinical care and without any formal cognitive assessment, delirium was often
unrecognized. Nurses were asked to rate the presence of delirium, as well
as specific delirium features, using the CAM. Despite prompting by trained
researchers, nurses properly identified delirium in only 19% of observations
overall and in only 31% of patients where present. In addition, nurses were
able to identify key features of delirium (ie, inattention, disorganized thinking,
and altered level of consciousness) in only 15% to 26% of patients. Thus,
compared with ratings by trained researchers after cognitive assessment including
the MMSE, nurses had generally low sensitivity for detection of delirium or
specific delirium features, and delirium was usually unrecognized. However,
the specificity of nurse ratings was high for detection of delirium or specific
delirium features; thus, delirium was rarely identified when it was not present.
Nearly all disagreements between nurse and researcher ratings were because
of underrecognition of delirium or its features by nurses.
The study findings confirm those of the original CAM validation study13 that the proficiency and thoroughness of the primary
observations on which the ratings are based substantially influence the effectiveness
of the CAM for delirium screening. These findings are comparable to those
of previous studies. Rockwood et al4 found
a substantial false-negative rate (32%), but few false-positives (3%) when
ratings by nurses were compared with those by study physicians using delirium
criteria from the Diagnostic and Statistical Manual of Mental
Disorders, Revised Third Edition.30
In another study,12 the false-positive rate
was somewhat higher, 10 (18%) of 55 patients, and false-negative ratings were
not assessed.
Four independent risk factors for underrecognition of delirium by nurses
have been identified: presence of the hypoactive form of delirium, age 80
years and older, vision impairment, and dementia. When all 4 of these risk
factors were present, the risk of underrecognition was increased more than
20-fold. Twenty years ago, Wolanin and Phillips31
cited the failure of nurses to identify the hypoactive form of delirium because
such patients tended to cooperate with their care. Nurses tended to label
patients as delirious when their behavior made them difficult to care for.
Palmeteer and McCartney32 reported that nurses
did not recognize cognitive impairment in a substantial proportion of older
hospitalized patients compared with researchers using a standardized tool.
Nurses tended to use patient behavior as an indication of cognitive function,
and they mistook compliance as an indication of intact cognition. Thus, cooperative
patients with hypoactive delirium were consistently not identified. In addition,
a recent study33 noted that nurses tended to
overlook symptoms of delirium in patients with dementia. The recognition of
risk factors associated with poor recognition offers the opportunity to heighten
the awareness of health care providers to situations in which delirium is
likely to be missed. Exploration of the effect of different pathogenic mechanisms
on the recognition of delirium is an important area for future research.
The poor recognition of disorientation and memory impairment by nurses
was likely due to the lack of assessment of these important domains. Previous
studies have found that nurses tend to rely considerably on the presence of
disorientation for detecting delirium; yet, disorientation alone—particularly
in hospitalized older patients—tends to lack sensitivity and specificity
for delirium.34 Palmateer and McCartney32 demonstrated that nurses were not knowledgeable about
cognitive assessment, dementia, or delirium. Only 35% of nurses passed a knowledge
test, and most did not consider cognitive testing to be a high priority in
the clinical care of older patients.
The strengths of the present study include the quality and consistency
of the reference standard ratings for delirium, which have been previously
validated.13-14 In addition, the
large sample size and wealth of patient-related risk factor data to examine
as potential predictors of underrecognition of delirium by nurses are important
advantages. Finally, the multiple paired ratings per patients enabled us to
examine the full range of performance across pairs and to select best case
and worst case comparisons—providing a sensitivity analysis of our results.
Best case comparisons were used for later analyses to provide the optimal
assessment of nursing performance.
Several important caveats deserve comment. First, nurses often varied
between observations on the same patient. In addition, nurses differed widely
in how well they knew the individual patients and their level of clinical
experience with older patients. These factors, however, are likely to reflect
real-world practice in the general hospital setting. Moreover, this study
was performed at a large academic teaching hospital, where nursing turnover
is relatively high. Although internal validity should not be compromised,
the study results may not generalize to all settings, particularly to centers
where nursing turnover is low or where geriatric nursing expertise is high.
Furthermore, the nursing environment has changed since the time this study
was completed. Although nurses continue to have the most frequent and continuous
contact with patients, the quantity and quality of that contact have been
compromised by contemporary acute care delivery models, with decreased nursing
staff ratios and substitution of unskilled patient care assistants.35
This study holds substantial implications for care of hospitalized older
patients. Although physicians often do not identify delirium in their hospitalized
older patients,4-7
they typically see patients for only brief periods and rely heavily on nursing
observations for issues such as mental status changes. The inability of nurses,
who have 24-hour contact with patients, to identify delirium is of perhaps
greater concern. Nurses are at the front line in the process of delirium recognition,
and improvements in this process will be essential to make any inroads to
addressing the problem of delirium.36-38
Education and training are needed for detection of delirium and its key features
by nurses during routine clinical care. Instruction in use of brief cognitive
assessment is required or these key features will be missed.39
Such education should ideally start in nursing school and should be an important
component of continuing education programs for the nursing profession.
Strategies to enhance training and education for recognition of delirium
will likely require substantial effort on the part of all health care providers—nurses
and physicians alike—and changes in current health care practices. A
widespread, brief nursing mental status assessment of hospitalized older persons
would represent a tangible start to this process. Although imposing some burden
on staff time, the costs should be more than offset by savings resulting from
early recognition and intervention for delirium, which is associated with
substantial morbidity and mortality rates and poor hospital outcomes. Without
the ability to recognize delirium promptly, intervention strategies to decrease
its impact will have limited success, and evaluation of the effectiveness
of prevention programs will not be possible. Future studies are needed to
examine whether implementation of the recommended strategies, such as education
and training of nursing staff in delirium recognition, routine cognitive assessment
of older patients, and heightened awareness to high-risk patients, would result
in improved recognition of delirium and reduction in its adverse outcomes.
AUTHOR INFORMATION
Accepted for publication March 13, 2001.
This study was supported in part by grant RO1AG12551 and Midcareer Award
K24AG00949 (Dr Inouye) from the National Institute on Aging, Bethesda, Md;
by in-kind support from the Claude D. Pepper Older Americans Independence
Center (P60AG10469) from the National Institute on Aging; and by Donaghue
Investigator Award DF98-105 from the Patrick and Catherine Weldon Donaghue
Medical Research Foundation, West Hartford, Conn (Dr Inouye). This article
was completed while Dr Inouye was working on research travel grant 1001225
from the Burroughs Wellcome Fund, Morrisville, NC.
We thank the nurses, patients, and families from Yale–New Haven
Hospital who participated in this study and research staff at the Yale Program
on Aging. This work is dedicated to Benjamin, Joshua, and Jordan Helfand.
Corresponding author and reprints: Sharon K. Inouye, MD, MPH, Yale
University School of Medicine, Yale–New Haven Hospital, 20 York St,
Tompkins 15, New Haven, CT 06504.
From the Departments of Internal Medicine (Drs Inouye and Cooney) and
Epidemiology and Public Health (Ms Katz), Yale University School of Medicine,
New Haven, Conn; the Department of Medical-Surgical Nursing, University of
Illinois at Chicago College of Nursing (Dr Foreman); and the Division of Nursing,
Cleveland Clinic Foundation, Cleveland, Ohio (Dr Mion).
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