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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

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Chapter 18Medication Management of the Community-Dwelling Older Adult

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For many older adults, the ability to remain independent in one’s home depends on the ability to manage a complicated medication regimen. Nonadherence to medication regimens is a major cause of nursing home placement of frail older adults.1 In the United States, an estimated 3 million older adults are admitted to nursing homes due to drug-related problems at an estimated annual cost of more than $14 billion.2 Older adults are the largest users of prescription medication, yet with advancing age they are more vulnerable to adverse reactions to the medications they are taking. Approximately 30 percent of hospital admissions of older adults are drug related, with more than 11 percent attributed to medication nonadherence and 10–17 percent related to adverse drug reactions (ADRs).3–5 Older adults discharged from the hospital on more than five drugs are more likely to visit the emergency department (ED) and be rehospitalized during the first 6 months after discharge.6 Nursing interventions that assist older adults in managing their medications can help prevent unnecessary, costly nursing home admissions, hospitalizations, and ED visits, as well as improve their quality of life.

The purpose of this review was to identify evidence-based interventions related to medication management and the community-dwelling older adult. The focus of this review was interventions that fall within the scope of practice of the registered nurse. The guidelines do not address the specific intervention of medication prescribing. However, the interventions are applicable to professional nurse providers whether they are prescribing or not. This chapter discusses risk factors for problems in medication management followed by evidence-based interventions in areas of medication reconciliation, medication procurement, medication knowledge, physical ability, cognitive capacity, intentional nonadherence, and ongoing monitoring.

Risk Factors

There is a wide variety of factors that place the community-dwelling older adult at risk for problems in medication management. The young-old (ages 66–74) have been found to be more adherent to medication regimens than middle-aged older adults, but after age 75, older adults present decreased comprehension of medication instructions and adherence.7–15 Living arrangements influence the older person’s ability to manage medications, and older adults who live alone were found to be more prone to medication errors.16–21 It is postulated that this is related to the fact that there is no one to monitor, assist, or remind the older person about taking their medications. Persons with chronic disease, especially depression, have a higher incidence of nonadherence to their medication regimen.7, 10, 22–30 Many of the risk factors related to inadequate medication management are items that are more prevalent in older adults living in the community. Other factors that will be discussed in more detail later in the chapter are physical impairments such as poor vision, grip strength, and cognitive decline.

Older adults are more prone to adverse events due to the clinical complexity of their care rather than age-based discrimination.31 A study of older adult outpatients who took five or more medications found that 35 percent experienced adverse drug events.32 In addition, individuals with complex regimens had difficulty naming and explaining the purposes of medications and appeared to be at high risk for nonadherence.33 The greater the medication complexity, the less likely the older adult is to adhere to the medication regimen.34 The larger the number of medications, the more likely the older adult will be nonadherent.3, 9, 13, 19, 28, 35–46 It is not only the number of medications but also the number of doses per day and actions related to taking medications that contribute to complexity of a medication regimen.34 In a study of medication compliance, the compliance rate was 87 percent for daily dosing, 81 percent for twice a day, 77 percent for three times a day, and 39 percent for four times a day.47 In addition, a change in prescribed drug regimen has been found to be a predictor of medication nonadherence in older adults.9 Finally, the number of prescribing providers adds to the complexity of managing one’s medications, and persons with more than one prescribing provider were found to be prone to medication errors.16, 19

Research Evidence

Medication Reconciliation

Medication reconciliation is the first step in assisting older adults in the medication management process. Multiple studies have demonstrated discrepancies from 30 percent to 66 percent in what medications were ordered by the prescribing provider and the actual medications the older adult was taking.16, 48–52 Prescribing providers were often unaware of prescribed medications their patients were taking,16, 53–55 and the larger the number of prescribing providers, the greater the chance of medication discrepancies.3, 42, 56, 57 A study of elderly patients 2 days after hospital discharge found 64 percent were taking at least one medication that was not ordered, 73 percent failed to use at least one medication according to instructions, and 32 percent were not taking all drugs ordered at discharge.58 Another challenge in reconciliation of medications is determining exactly what medications older adults are taking in their home. One study found 49 percent of community-based older adults kept stores of old medications from the year before, and 6 percent admitted they self-prescribed medications on at least one occasion.59 Over the counter (OTC) medication use also needs to be assessed, because estimates of older adults’ use of OTC drugs range from 32 percent to 86 percent.60–62 A recent study of older adults with hypertension attending a blood pressure clinic found 86 percent reported two or more self-medication practices using OTC drugs that could result in an adverse drug interaction.63

Multiple studies have demonstrated that 10–74 percent of medications prescribed for older adults were inappropriate.48, 57, 64–74 A study of “brown bag” medication reviews, in which patients bring all of their medications with them (often in a brown paper bag) to a medical or pharmacy consultation, revealed that 12 percent of the patients had medication problems that could potentially result in hospital admission.75 A review of ED visits of patients 65 years and older found 10.6 percent of the visits were related to an adverse drug event, and 31 percent had at least one potential adverse drug interaction in their medication regimen.

Pharmacy reviews have demonstrated a reduction in polypharmacy in older adults and decreased adverse drug events in older patients.76–82 Beer’s set of criteria for potentially inappropriate medication use in older adults is one example of criteria developed for pharmacy screening.83, 84 There are a variety of drug interaction programs that quickly identify adverse drug interactions.

Also, patients who were given a medication card with a list of current medications were more compliant with their medication regimen.85 Use of a medication list that is shared with the patient’s primary care physician decreased patient rehospitalizations in one study.86

Medication Procurement

Not filling or refilling prescriptions is a common cause for medication nonadherence in older adults.87–91 In a study of elderly patients at 15 days posthospitalization, 27 percent had not filled their new prescriptions.92 Patients who participated in programs that provided pharmacy delivery and refill reminders had fewer adverse drug events and higher compliance than those who did not.78

If the cost of medication is viewed as high, older adults are more likely to not adhere to their medication regimen and be hospitalized.3, 11, 56 Lack of funds, especially at the end of the month, is one reason older adults delay filling prescriptions.93 In addition, chronically ill older adults are more likely to experience financial burdens associated with covering out-of-pocket costs for their prescription medications, cut back on medications due to cost, and use less medicines monthly.89, 93–98 A study of use of medications after an increase in the copayment found a reduction in use of up to 45 percent in nonsteroidal anti-inflammatory drugs and 23 percent in antidiabetic drugs.99

Older adults who have insurance to cover medications have greater adherence.12, 14, 19, 100 In one study, both adherence to medications and clinical outcomes improved while the number of hospitalizations declined when cardiovascular drugs were provided to indigent patients who could not afford to buy them.101

Medication Knowledge

Studies of older adults’ knowledge of medications have found more than 50 percent knew the names and purpose of their medications; however, less than 25 percent knew the consequences of drug omission or toxic side effects.9, 16, 54, 102 For example, one study of elderly patients with congestive heart failure found that 30 days after a new medication was prescribed, only 64 percent of the patients could identify when they were supposed to take their medicine.103 Also, older adults were found to have insufficient knowledge of inhaler technique and understanding how medications can improve their asthma.104 Noncompliant patients on anticoagulant therapy were more likely to report they did not know why their medication was prescribed.105 In a study of OTC medication use, few older adults knew precautions related to the OTC drugs they were taking.61 One study of older adult medication knowledge found that older adults understood prescribed medications better than OTC drugs, especially nutritional supplements.106

Patient education is a key intervention to assist older adults with medication management. Patient knowledge of drugs is positively associated with adherence.16, 21, 91, 105, 107–112 However, older adults require specific educational methods. Learning is more effective in older adults if information is explicit, organized in lists, and in logical order. Instructions that are compatible with the older adults’ schema for taking medications are better remembered,113 and well-organized prescription labels are more useful for older adults.114 Pictures are not helpful unless the picture is clearly related to the content.115–118 A combination of both oral and written formats was identified by older adults as most helpful.119 Medication schedules or charts in combination with teaching or counseling enhances patient medication adherence.85, 86, 120–124 Four weeks after starting a new medication for a chronic illness, patients identified a substantial need for further information.125 Studies have demonstrated that patient education and counseling over several home visits or with followup phone calls produces increased medication adherence in recipients.126–141

Physical Ability

Poor vision and low manual dexterity are associated with poor medication self-management.9,21,39,142–144 The inability to read medication labels has been associated with nonadherence to long-term medications in the elderly.43,145 One study found 28 percent of community-based older adults did not keep their medication bottles properly closed so that they could open them, and 47 percent admitted that labels on their medications were unclear and they could not read them due to poor eyesight, inability to read English, or small writing on the label.59 Studies have demonstrated that from 31 percent to 64 percent of older adults living at home have difficulty opening medication containers, with childproof containers presenting the most difficulty.9,144,146 In studies of persons with chronic obstructive pulmonary disease (COPD), 38 percent used their inhaled medications with poor technique,89 and poor hand strength was associated with nonadherence in inhaler use.147 In another study of COPD patients, more than 50 percent had difficulties with their inhalers.112

Medication-container modification is one area of intervention for older adults who have difficulty opening or reading containers. Use of nonchildproof containers is one option for older adults. However, blister packs or other variations of unit dose packaging have resulted in increased compliance.148–150 In a recent study of older adults, 64 percent were unable to open childproof containers, and 10 percent were unable to use blister packs.9 Also, different tablet formations that increase the ease of breaking tablets have been found to increase patients’ abilities to comply with their medication regimen.151 Finally, talking medication containers and large-print labels are modifications that can be useful for persons with visual impairment.

Cognitive Capacity

Poor cognition is associated with both over adherence and under adherence of a prescribed medication regimen.9,14,18,28,37,38,142–144,152–155 A study of community-dwelling women found that 22 percent were unable to accurately perform a routine medication regimen; however, only 2 percent self-identified that they had difficulty with their medications.156 Forgetting is a major reason medication doses are missed.9,78,88,89,157–162 The most prominent type of medication noncompliance is dose omission, but overconsumption is a common mistake, especially in persons on a once-daily dose schedule.163

There are a number of interventions to assist older adults with remembering to take their medications. One simple method is the use of memory cues that prompt patients to take their medications.148 Development of memory cues must be tailored to the patient’s lifestyle.90,164 Placing medication in a special place and use of a daily event such as meal time improve medication adherence.91,106,165,166 A study that examined the most common ways older adults remembered to take their medications found the following methods to be beneficial: (1) placing containers in a particular location, (2) taking medications in association with meals/bedtime, (3) using a timed pill box, (4) reminders from another person, and (5) using written directions or a check-off list.159

Compliance aids such as pill box organizers have been found to increase medication adherence.16,78 Medication schedules and calendars are helpful, especially in combination with education and use of a pill box.38,40,78,120,150,167,168 In addition, electronic monitoring that provides feedback to the user increases adherence.141,169–171 Older patients using a voice-reminder-message medication dispenser were significantly more compliant than those using a pill box or self-administering medications.172,173 Patients using topical pilocarpine were significantly more compliant using an electronic medication alarm device.174 Programs that use daily telephone reminder calls also have demonstrated increased medication compliance.155,175 Several studies have demonstrated that dose simplification from two times a day to one time a day produces higher compliance and improved patient outcomes.122,176–182

Intentional Nonadherence

One study of chronically ill persons who were starting a new medication found that almost a third did not take their medication as prescribed, and half of the time it was deliberate.125 Older adults’ perceptions of the seriousness of their illness and vulnerability to complications were significantly related to medication adherence.13,46,90,91,97,166,183 In fact, low self-efficacy and beliefs that others are responsible for one’s health care are predictors of medication nonadherence.21,89,105,159,184–194

A major reason that older adults skip doses or stop taking their medications is related to medication side effects.9,11,16,26,38,46,89,91,93,110,125,159,161,162,191,195–198 In a comparison of compliant and noncompliant patients in fluvastatin treatment, the noncompliant patients were more likely to experience side effects of the medication.199 Six months after discharge for acute coronary syndrome, 8 percent of those taking aspirin,12 percent of those taking beta-blockers, 20 percent of those taking ACE inhibitors, and 13 percent of those taking statins had discontinued taking their medications.200

Use of commitment-based interventions has been found to increase self-efficacy and medication compliance.201 Education that addresses patient involvement with decisionmaking, such as focusing on appropriate versus inappropriate use of medication, can improve self-efficacy.202 Patients with depression who participated in a program to enhance self-management and prevent relapse had significantly greater long-term adherence to their medication regimen.203 Patients whose provider had an open, collaborative communication style also were more adherent to their medication regimen.204

Ongoing Monitoring

Older adults have narrow therapeutic windows and require close monitoring, especially when on multiple medications.205 Ongoing monitoring of the older adult’s medication management is critical. A study of home care patients found 16 percent had skipped a medication in the last 24 hours, 6 percent were taking the wrong dose, and 5 percent were experiencing adverse effects from their medication.87 In one study, symptomatic hypotension was identified in 13 percent of community-based elderly.67 In another study, older adults treated for urinary tract infections and sleeping disorders experienced a significantly higher risk of ADRs.206 A review of ED visits of patients 65 years and older found 10.6 percent of the visits were related to an adverse drug event, and 31 percent had at least one potential adverse drug interaction in their medication regimen.207 Pharmacist management of repeat prescriptions found 12.4 percent of patients had compliance problems, side effects, ADRs, or drug interactions.208 A total of 35 percent of elderly ambulatory patients reported at least one adverse event within the previous year.209

Monitoring medication adherence is an ongoing process. The longer people are on a medication, the more likely they are to have difficulty following the medication regimen.179, 210 For example, in one study, only 31 percent of people with type 2 diabetes who were on oral hypoglycemics adhered to their medication regimen.211 In another study, persons on oral hypoglycemic medications were nonadherent an average of 64.7 days in one year.212 Since adherence to medication regimen for type 2 diabetes is strongly associated with metabolic control, interventions related to monitoring and improving adherence are critical.213

Patients taking Digoxin who are not adherent have an increased number and duration of hospitalizations and twice the mortality rate than those who are adherent.214 Also, in a study of long-term compliance of antihypertensive drugs, patients on ACE-inhibitors, beta-blockers, calcium channel blockers, and diuretics were more likely to be noncompliant,215 as were persons using bronchodilators and benzodiazepines.60

Practice-Implications: Medication Management Practice Guidelines

Medication Reconciliation

  1. Review with patient all prescribed and nonprescribed medications the patient is taking. Include over-the-counter (OTC) medications, herbs, and vitamins.216
  2. Screen for adverse drug interactions. If adverse drug interactions are identified, report to the prescribing provider any medications of concern.76–82,84,216
  3. Identify the primary or secondary medical diagnosis related to each prescribed medication. If the medical diagnosis is unknown, request the diagnosis from the prescribing provider.84,216
  4. For patients age 65 and older, apply Beer’s criteria for inappropriate medication for the elderly. If any medications appear in Beer’s criteria, report to the prescribing provider any medications of concern.84
  5. Provide to the prescribing provider(s) a list of all medications (prescribed and OTC) the patient is taking and a list of corresponding medical diagnoses.216
  6. Verify prescribed medications and related medical diagnoses with the prescribing provider(s).84
  7. Provide the patient or caregiver a current list of all medications the patient is taking with dose and frequency; have the patient share this list with the prescribing provider or other health care providers as needed.85,86,216

Medication Procurement

  1. Assess the patient’s or caregiver’s ability to procure medications.87–92
    1. Identify how and where the patient obtains and refills prescriptions.87–92
    2. Assess how the patient pays for medications.3,11,56
    3. Assess if medications doses are ever missed due to lack of funds.93
  2. If the patient or caregiver has difficulty obtaining or refilling prescriptions, assist the patient with creating a system to procure medications via
    1. Pharmacy delivery.78
    2. Refill reminders or automatic refill service.78
    3. Scheduling family or friends to pick up medications.
  3. If funds to purchase medication are a problem,89,93–98
    1. Refer the patient to a social worker to obtain Medicare Part D coverage, other insurance coverage, or participation in drug company programs.12,14,19,99,100
    2. Consult with the pharmacist regarding use of generic drugs.
    3. Consult the prescribing physician about availability of drug samples.101

Medication Knowledge

  1. Assess the patient’s or caregiver’s knowledge of
    1. Dose and frequency of medications taken.9,16,33,54,102,103
    2. Special instructions related to medications, such as “take with food.”33
      1. If the patient uses an inhaler, understanding of the correct inhaler technique.104
    3. Medication mode of action.9,16,54,102
    4. Side effects to monitor and report.9,16,54,102
  2. With each change in medication regimen (including OTC drugs), review medication purpose, dosage, frequency, side effects to monitor and report, and other medication-specific instructions.61
  3. Interventions related to medication knowledge include16,21,91,105,107–112
    1. Provide written instructions related to medications in large letters and bullet or list format.115–119
    2. Tailor instructions to how the patient takes his or her medicine.113
    3. Group information starting with generalized information, followed by how to take the medicine, and then the outcomes such as side effects to watch for and when to call the doctor.114–118
    4. Use medication schedules or charts to reinforce instructions.85,86,120–124
    5. If the patient did not know important medication information at a previous encounter, review dose, time, side effects to monitor and report, and special instructions at the next visit.125–141

Physical Ability

  1. Assess for decreased manual dexterity or vision impairment and its affect on the patient’s ability to identify the correct medication, open medication containers, and prepare medications (e.g., breaking tablets) for administration.9,21,39,43,142–145
    1. Observe the patient opening medication containers.9,59,144,146
    2. If the patient uses an inhaler, observe the use of the inhaler.89,112,147
    3. If the patient is required to break tablets, assess his or her ability to do so.151
    4. If the patient is unable to open or see the label and contents of each medication container, provide one of the following:
      1. Pill box or other easy-open container.150,172,217 If the patient is unable to fill the pill box, identify someone who can assist him or her.
      2. Medication calendar with pill box.155,167,168,218
      3. Blister packs.138,149 Consult the pharmacy about the availability of the drug in blister packs or nonchildproof containers.
      4. If tablet breaking is required and the patient has difficulty doing it, consult with the pharmacist about tablets that are easier to break or tablets that are the correct dosage without requiring breaking.151

Cognitive Capacity

  1. Assess the patient’s or caregiver’s cognitive capacity to organize and remember to administer medication.106, 156
    1. Assess when doses are taken.
    2. Assess what cues the patient uses to remember to take medication.
    3. Assess what dose is most difficult to remember.9,78,88,89,157–162
    4. Assess how often a dose is missed or an extra dose is taken.9,14,18,28,37,38,142–144,152–155
  2. Teach the patient or caregiver the use of memory cues based on one of the following methods:148,159
    1. Clock time. Ask if the patient or caregiver is usually aware of the time of day or keeps track of time through a watch or clock.
    2. Meal time.90,91,106,164–166 Ask if the patient eats meals at a regular time.
    3. Daily ritual, such as using the bathroom in the morning, shaving, or hair combing.90,91,106,164–166
  3. If the patient requires additional support,
    1. Provide memory-enhancing methods or devices such as
      1. Medication calendar or chart.38,40,78,120,150,167,168
      2. Electronic reminder or alarm.141,169–171,174
      3. Voice-message reminder.172,173
      4. Telephone reminder.155,175
      5. Pill box.16,78 (If the patient is unable to fill a pill box, identify someone who is willing to assist him or her.158)
      6. Electronic medication dispensing device.173
      7. Combine methods and devices when possible.38,40,78,120,150,167,168
    2. Discuss dose simplification with the prescribing provider.122,176–182

Intentional Nonadherence

  1. Assess if medication doses are missed intentionally.125
    1. Drugs at high risk for intentional noncompliance include the following:
      1. ACE-inhibitors200,215
      2. Beta-blockers200,215
      3. Calcium channel blockers200,215
      4. Diuretics215
      5. Bronchodilators60
      6. Benzodiazepines60
    2. If the patient intentionally misses doses, assess the reason(s).
      1. Belief medication is not helping.13,46,90,91,97,166,183
      2. Fear of adverse side effects.13,46,90,91,97,166,183
    3. The following medications are most risky for patients to miss:
      1. Coumadin105
      2. Digoxin214
      3. Beta-blockers200
      4. Insulin
      5. Prandinm® (repaglinide)
      6. Antibiotics
      7. ACE-inhibitors200
  2. If the patient misses medication doses for reasons related to health beliefs,
    1. Explore with the patient his or her health concerns for not taking medication.202
    2. Discuss the benefits of taking medication as prescribed.202
    3. Provide positive reinforcement for taking medication as prescribed.201
  3. For patients on high-risk medications, reinforce the danger of missing medication doses.105
  4. If the patient misses medication doses for reasons related to medication side effects,
    1. Explore with the patient a plan to manage the side effects.203
    2. Modify the regimen to reduce the side effects.

Ongoing Monitoring

  1. For all patients on a prescribed medication regimen, monitor the patient with each encounter for the following:
    1. Medication adherence
      1. Monitor both under- and overadherence.87,179 Overconsumption occurs frequently in a once-daily dose schedule.
      2. For persons using inhalers, assess
        1. Inhaler emptying rate.89,104,147
        2. Reported forgetfulness.104
        3. Use of short-acting inhaler.89,104
    2. Medication side effects67,205
      1. If medication side effects present, notify the prescribing provider, as appropriate.
    3. Lab work, as appropriate, for prescribed medications216
      1. Cockcroft-Gault Formula or other creatinine clearance measure at least annually. If creatinine clearance <50 ml/min, notify the prescribing provider.
    4. Medication effectiveness205
      1. If signs and symptoms of the problem the medication is treating are present, notify the prescribing provider, as appropriate.

Research Implications

There is a large volume of research related to medication management and the elderly. Medication management is a complex process that must be interdisciplinary in its approach. Many of the evidence-based interventions discussed are not discipline specific. A team of providers is needed to provide safe and therapeutic medication management.

There is a large amount of research related to risk factors for medication nonadherence. However, there is less evidence related to appropriate interventions to enhance adherence and medication self-management. In addition, the most effective programs have multiple interventions, so identifying the specific evidence for each intervention component is difficult. For example, one study included a combination of interventions of medication review, modification of containers, medication education, and a drug reminder chart.138 All are important components of a medication program for older adults, yet it is difficult to identify the evidence supporting each component. What is promising is the use of technology to assist in medication management.173,219 This includes clinical screening software for adverse drug interaction and potentially inappropriate prescribed medications, electronic adherence monitoring, and electronic medication reminders. Much of this new technology is currently being tested.


Medication management is a complex process that consists of multiple activities. Factors associated with problems in the performance of these activities include living alone, impaired vision, impaired cognitive function, ages 75 and older, having three or more medications and/or scheduled doses in one day, and more than one prescribing provider. Medication reconciliation is a key first step in medication management. Multiple studies have demonstrated large discrepancies in what medications are ordered by the prescribing provider and the actual medications the older adult is taking. Evidence supports medication reconciliation interventions that include a screen for inappropriate medications and adverse drug interactions, in addition to verification of medications that are prescribed. Other areas of medication management include assessment and interventions related to medication procurement, medication knowledge, physical ability, cognitive capacity, and intentional nonadherence. Ongoing monitoring of these areas is crucial.

Nurses play a pivotal role in the medication management process of older adults. Considering the expense of prescription drugs in the current health care system, a small investment in providing comprehensive assessment and interventions to assist older adults in accurate and safe management of their medications will provide cost-effective care and increase the quality of life of older adults struggling to manage their often-complex medication regimens.

Search Strategy

To conduct this review, a search was done in August 2005 of PubMed®, the Cumulative Index to Nursing & Allied Health Literature, Cochrane Database of Systematic Reviews, HealthStar, ISI Web of Science, Social Service Abstracts, Database of Abstracts of Reviews of Effectiveness, and Internet searches for citations occurring from January 1990 to August 2005. Key search terms used alone and in combination included medication adherence, compliance, elderly; aged; outcomes; polypharmacy; medication management; chronic illness; chronic disease; and individual types of chronic illnesses. All searches were limited to patients ages 65 and older and Web sites in the English language. The ISI Web of Science was used to track citations to major works, and article references were reviewed for inclusion. Bibliographies of retrieved articles also were searched for relevant articles not identified in the reference database searches.

Evidence Table

Evidence Table

Medication Management of the Community-Dwelling Older Adult (Includes studies design level 4 and above)



Development of the Medication Management of Community-Based Older Adult Guidelines was partially funded by the Aurora-Cerner-University of Wisconsin Milwaukee (ACW) Knowledge-Based Nursing Initiative. The authors would like to thank Lenore R. Wilkas, M.L.S., for her expert assistance.


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