Meeting the needs of Maori with diabetes: Evaluation of a nurse-led service.
Aims and objectives. To explore the effectiveness and acceptability of a nurse-led Maori diabetes programme run by Te Hauora O Ngati Rarua for their clients.
Background. Nurses have a key role in diabetes management, but little is known about nurse-led services for indigenous populations. The Te Hauora O Ngati Rarua programme consisted of an education course, case management and support services.
Design and methods. An embedded case study evaluation was used. Data sources included: i) documentation, ii) interviews with clients (n=7) and health practitioners (n=5), iii) pre and post-course physiological, knowledge and lifestyle behaviour client data, and iv) researcher observation. Results were triangulated and organised using the Wagner Chronic Care Model.
Results. The programme successfully addressed all elements of the Chronic Care Model. It was culturally appropriate, supportive and beneficial to the clients in meeting their health objectives. Staff demonstrated high levels of goodwill and commitment to clients and the organisation. Relaxed interpersonal relationships, especially the use of humour encouraged clients to remain engaged with the service and to make lifestyle changes. A high prevalence of co-morbidities impacted on clients' ability to self-manage their diabetes. Four clients had short term improvements in health outcomes, but were unable to maintain these when programme support reduced. All clients gained new knowledge and awareness related to diabetes and how to make personal changes.
Conclusions. This study confirms the importance of providing 'culturally appropriate' health services delivered by specialist Maori nurses. Targeted diabetes programmes need to recognise the complexity of clients' day-to-day lives and co-morbidities as part of increasing client self-management. Clients need both short and long term professional and peer-group support to make and sustain changes.
Relevance to clinical practice. The findings can be used by nurses to assist people with diabetes to make sustainable changes to improve their health outcomes.
Maori, Indigenous, Diabetes, Nurse-led, Case study
Nurse-led programmes play an important role in providing expert education and management in the primary health care (PHC) of people with chronic illnesses. This study examined how a nurse-led diabetes programme set up by Te Hauora O Ngati Rarua, a Maori health provider, was effective in addressing the needs of clients. Effectiveness is viewed from a number of perspectives including: cultural appropriateness, integration with the community, accessibility, consumer participation and satisfaction, and health outcomes. The paper is in four sections: A background on health disparities and Maori, then methods, findings generated from a case study of the Te Hauora O Ngati Rarua service, and discussion.
In Aotearoa/New Zealand, ethnic inequalities between Maori and non-Maori are the most consistent and compelling inequities in health. For example, Maori die on average 8.2 years younger than non-Maori (Statistics NZ, 2009). Of particular concern is the high Maori mortality from diseases that are amenable to treatment, such as diabetes, which affects Maori at a younger age, leading to higher rates of serious diabetic complications and a mortality rate which is four times higher than for non-Maori (Coppell et al., 2013; Statistics NZ).
A focus for the New Zealand health system is to develop acceptable and accessible PHC services to keep people well and out of secondary services. To this end the Government funded 264 Maori organisations to provide affordable health services for their people (MOH, 2011). Kaupapa Maori providers attempt to ensure that client access to health services is unimpeded in cultural, financial or social terms, by offering 'by Maori, for Maori' services that incorporate traditional Maori practices and values (Boulton, Tamehana & Brannelly, 2013). As such, the Te Hauora 0 Ngati Rarua programme was centred on a Diabetes Nurse Educator role, which provided continuity of care across primary and secondary services. While this PHC nursing role has now been replaced by a generalist chronic disease state management role, the insights gained from the evaluation of this diabetes specific programme remain relevant. The findings are important for all nurses working with people (especially Maori) with any chronic condition.
Research on disparities in health outcomes between Maori and non-Maori has been largely descriptive, identifying and defining the severity of diabetes within communities and different ethnic groups (Coppell et al., 2013; Lim, Chellumuthi, Crook, Rush & Simmons, 2008; Simmons, Rush & Crook, 2009a), and identifying barriers to accessing care (Baxter, 2002; Simmons, Lillis, Swan & Haar, 2007). Some large intervention studies have been undertaken (Coppell et al., 2009; Simmons et al., 2009b), but little is understood about the delivery and experiences of Maori attending targeted diabetes programmes.
A number of studies have evaluated Maori health providers including monitoring client utilisation and satisfaction. Maori were found to access such providers because they were cheaper, geographically closer and offered culturally appropriate services (MOH, 2010; Wilson, 2008). Some researchers have considered contractual and organisational issues for Maori providers (Abel, Gibson, Ehau & Tipene Leach, 2005; Boulton, 2007), while others have described aspects of nurse-led PHC services (Hotu et al., 2010; Riley & Crawford, 2010), and found that nurses are able to spend longer with clients and do opportunistic assessments leading to better outcomes. But no studies have focused specifically on nurse-led diabetes programmes.
Numerous international studies have explored the reach and effectiveness of diabetes management interventions and nurse-led services (Laws et al., 2012; Pun, Coates & Benzie, 2009; Smide & Hornsten, 2009), including programmes with indigenous populations and ethnic minorities (Ghosh & Spitzer, 2014; Lawrence, 2008). A New Zealand study found that nurses spent more time with newly diagnosed diabetes patients than other health professionals, but that the information imparted was guideline driven and not necessarily what the patient wanted to know (MacDonald et al., 2013). In another New Zealand study, practice nurses were found to be the clinicians who mainly delivered the Diabetes Annual Review "Get Checked" programme (Daly, Kenealy, Arroll, Sheridan & Scragg, 2013). Given New Zealand's health inequalities and the high incidence of diabetes amongst Maori it is important to understand the features and impact of Maori nurse-led services.
The study aimed to: develop an understanding of how the Te Hauora O Ngati Rarua programme provided a culturally appropriate service; identify the salient features for Maori clients of having diabetes and attending this programme; and identify the extent to which the programme contributed to an improvement in knowledge, diabetes monitoring, lifestyle behaviours and physiological outcome measures. The programme delivered one-to-one case management and education; a 6-week group education course, followed by an on-going Diabetes Support Group, and advised other providers about culturally appropriate services for Maori.
The research used a mixed method case study design. The case was the entire diabetes programme offered to the clients of Te Hauora O Ngati Rarua. Yin (2014) advocates that the examination of subunits of programmes can enhance the insights gained from a study. Figure 1 illustrates the relationship between the subunits of the study.
The research was initiated by the principal investigator, and the design was negotiated in consultation with Te Hauora O Ngati Rarua staff. The principal investigator met with staff, sharing the proposal and negotiated a partnership which respected client and staff privacy and rights, including providing the organisation with the right to review external reports and the choice to be involved in any publications. The partnership that developed followed that outlined by McCleland (2011) and included the principal investigator being mentored, forming a meaningful relationship (whakawhanaungatanga) with the service, recognising the concept of whanau (extended family group), networking with both clients and staff, and learning about and following "protocol". Recruitment into the research by people who were recipients of the programme was via the group education courses. All clients who attended the Te Hauora O Ngati Rarua diabetes courses were eligible. The study received approval from the Upper South A Regional Ethics Committee. Data collection took place from May 2006 to May 2008.
Conducting culturally competent research
Throughout the research attention was given to ensuring the research was culturally safe and responsive, as the principal investigator is a Pakeha (non-Maori). Safety for participants was ensured by giving choices of where the interview took place and inviting interviewees to bring support if they wished. Safety also involved respecting what was shared and treating interviewees perspectives as important. Being culturally responsive included meeting the need for reciprocity by the investigator sharing personal information, offering gifts of kai (food) and having a flexible view on time to explain the study "kanohi ki te kanohi" (face-to-face) (Smith, 2005). Another consideration was recognising the power differential between the principal investigator and the participants and taking measures to minimise this. The latter included the principal investigator enrolling in a te reo (Maori) language course. The researchers had access to supervision and counsel from university and Maori researchers.
Of the 14 clients who attended one of the two education courses delivered during the research, seven consented to be involved. These clients were followed for 6-9 months; from the start of their group course until study completion. The five health practitioners, who consented, included three employed by Te Hauora O Ngati Rarua (diabetes nurse educator, the manager and a support worker) and two (dietician, fitness instructor) who worked for external organisations. The Te Hauora O Ngati Rarua staff all identified as Maori and the two external practitioners as Pakeha.
Yin (2014) identifies that case study can use a mix of quantitative and qualitative evidence and its unique strength is its ability to deal with a variety of evidence. In this study four sets of data were collected: programme documents; semi-structured interviews with clients and health practitioners; physiological measures of clients; and observation.
Documents reviewed included course and service documents. Clients were interviewed on two occasions; post the education course and at study completion. Health practitioners were interviewed following the education course. All interviews were audio-taped and transcribed. To determine how the programme met clients' needs, clients were asked at interview for a self-assessment of their learning and behaviour change following the education sessions, and what they valued about the service including its cultural approach. In addition, changes in clients' recorded measures (blood pressure, weight, HbAlc [blood sugar level]) were calculated over time (start and end of the education course, and end of study). Health practitioners were questioned about their preparation for their role in the programme, and the content and cultural aspects of the programme. The principal investigator observed two group education courses.
Information was collated from programme documents regarding the service's structure and objectives. Analyses of the interview transcripts and observational data were ongoing and iterative throughout the research, and informed the ongoing research design, while also providing findings (Thomas, 2006). First level analysis for each interview followed the interview topics such as "introduction to the service", "lifestyle change", "resources" and "Maori programme". Areas for additional information were followed up in the second interview.
Cultural appropriateness of the service was determined by analysing clients' comments about the importance to them, as Maori, of aspects such as, flexibility, whanaungatanga and discussions about kai. Calculating the proportion of weight change involved an analysis of the difference between baseline weights with that at other times. In addition, means were used to calculate changes in physiological measures for the whole sample where available. Given the sample size inferential statistics were not used; the changes can therefore only be reviewed for clinical significance.
The data from all sources were triangulated to construct an understanding of the programme including the similarities and differences in perspective amongst clients and between clients and practitioners. As a result of this triangulation a number of themes were identified, for example time expectations placed on this Maori service by its clients. As part of the partnership agreement provisional findings and article draft were shared and refined with Te Hauora O Ngati Rarua staff.
Demographic information and diabetes status of the clients are shown in Table 1. Clients are referred to by their nominated pseudonyms and the practitioners by their role.
A finding among the seven clients was the number and severity of co-morbidities; which had a profound effect on clients' overall health. Co-morbidities included coronary artery disease, congestive heart failure, chronic obstructive airways disease, asthma, osteoarthritis, breast cancer, obstructive sleep apnoea and depression. Five clients had recently experienced depression, but only three were receiving antidepressants. Those whose depression was being managed were more engaged with trying to make change. According to the nurse educator this high level of co-morbidity was typical of Te Hauora O Ngati Rarua clientele on the diabetes register. Consequently the Chronic Care Model (Improving Chronic Illness Care, 2008) was identified as a suitable model to frame the study findings (Table 2). This model aligned with Te Hauora O Ngati Rarua's organisational values.
The programme successfully addressed all six elements of the Chronic Care Model (Wagner et al., 2001; Wagner et al., 2005). Given that the findings related to the Delivery system design and the Self-management support elements were particularly important, these are presented in greater depth, while the other four elements are only summarised. The organisation had strong links and partnerships with the local Community and other health providers. Requirements for Health systems were met by maintaining quality assurance and accreditation. Decision support was embedded in the programme through the application of evidence-based guidelines and specialist support. Clinical information systems including client case notes were fully computerised, which enabled sophisticated record keeping and reporting.
Delivery system design
The "Wellness with Diabetes" course consisted of six, weekly (2 1/2 hour) education sessions. The sessions included education on the pathophysiology of diabetes and its management, physical exercises, and participation in a supermarket tour focusing on interpretation of food labels. Clients were shown healthier ways of preparing traditional Maori meals. At the end of the course clients could continue to meet every six weeks at a Diabetes Support G roup. The course utilised a whanaungatanga (family togetherness) approach and the group became a diabetes whanau. The educational sessions used hui (meeting) protocols and cultural processes, such as starting and ending with karakia (prayers), waiata (songs) and sharing kai.
The sessions provided an opportunity for the staff to role model healthy eating choices and converse regarding lifestyle change. A distinguishing feature of the sessions was the use of humour, which staff used to give clients messages about aspects of lifestyle behaviour, without causing offence. Staff sometimes used humour in a self-deprecating manner; referring to their own body size as a way of showing clients they appreciated the difficulties of being overweight. This self-disclosure also allowed staff to share personal insights into the difficulties of making changes to improve their health.
Relationships between staff and clients presented as less formal than traditional professional relationships. The focus on whanaungatanga and reciprocity meant there was a need for personal disclosure and genuineness when dealing with clients, while also attending to professional boundaries. This appeared to be challenging when encouraging independence in clients who had become relatively dependent on the service. Clients appreciated the time and personal disclosure from the staff. Such disclosures were not only about health but also about whakapapa (iwi [tribal] location and family heritage).
Whanaungatanga, getting together, learning from, and being motivated by others with diabetes and sharing jokes and fun times, were cited as important by most clients. Here were other people who knew what they were going through; for those on tablets, such as Lee, it was a chance to hear about a possible future on insulin, while for those on insulin it was the opportunity to inform others. Toni, who had advanced diabetes, said "It's too late for me now" and "if only I had listened", which had a powerful effect on other members of the group.
In addition to the group sessions, the nurse educator met one-to-one with clients and whanau, providing self-management education and support, monitoring physiological indicators and delivering guideline-based treatment. The nurse educator and other staff negotiated the link between clients and 'mainstream' health and social services, often accompanying and supporting clients on appointments. Staff went to considerable lengths to keep clients engaged with the programme, reminding them about upcoming events, transporting, supporting, reinforcing and removing impediments to change. Decisions to stay into the evening or come in on their days off were viewed as a cultural commitment rather than an employment obligation.
The interviews revealed that some clients had not, as yet, accepted the diagnosis of diabetes, did not accept that lifestyle changes were important, or did not believe that they could make changes or commit to maintaining them. Several talked of the difficulty of accepting they had diabetes as they had continued to feel well for many years. For example, Lee commented "I felt o.k., looked o.k., not like having cancer, a cold, or a broken arm". Ali was unable to commence making changes until he had proof that he had type 2 diabetes. Motivation to change came from both intrinsic and extrinsic sources, for example Sam wanted to make changes for "the girls" (Te Hauora O Ngati Rarua staff) more than herself, an effort which ultimately proved difficult to sustain. A few clients identified concern about a possible future leg amputation as a motivation.
A common problem when improving their diabetes self-management was the debilitating and depressing effect of trying to make lifestyle change within the limitations of multiple co-morbidities. For example, Sam's necessity to snack between meals, regularly test her blood glucose and inject insulin, as well as stopping smoking, meant it was difficult for her to lose weight. Having conditions such as chronic obstructive airways disease, congestive heart failure and obstructive sleep apnoea impacted on many clients' ability to exercise. At the second interview Sam talked of a period of high motivation and intense change in which she established good routines, lost weight, only to lose confidence when she felt insufficient weight had been shed. Consequently she regressed to her previous lifestyle pattern, saying she was "hoha" (fed up and indifferent), and shared "It's not interesting anymore. It seems to be dead, you know it now". She and her partner were "living for the day" and "watching ourselves die away".
As only five participants had physiological data available at the three time points (start of course, end of course, and end of study) the analyses on changes were limited. The mean weight at the time points was 107.60kg, 105.40kgs and 108kg respectively, indicating that as a group there was no meaningful change in weight over time. These means do not correlate with the maximum improvement achieved by each participant though; calculation of the total body weight lost by individuals found that Lee and Casey had both lost 5%, Ali 6% and Sam 9%, but none were able to maintain the loss over the length of the study.
Similarly the mean blood pressure only changed minimally, the means being 134/92, 129/84 and 132/81, which indicates slight improvement for the group. In contrast, mean blood sugar levels (HbAlc -normal range 4.0-5.9%) improved from the baseline (9.54) while attending the education sessions (8.6), but progress reversed over the longer term (10.40). All clients identified that they learnt new information about diabetes and all had made some lifestyle changes while on the programme.
Successful change was found to positively affect many areas of the clients' life, while failure to achieve or maintain change was demoralising and undermined confidence. As the above commentary shows, sometimes it was a matter of taking two steps forward, then one, or even two steps back. Te Hauora O Ngati Rarua staff generally viewed regression as evidence that the timing was not right for people, as they currently had other priorities, while comments from clients suggested they often viewed the locus of control as being external to themselves. Some blamed the onset of their condition on stress or genetic predisposition, yet others indicated they had to test their blood sugar for the doctor who was the expert in managing their diabetes. The nurse educator challenged this understanding by asking the group "Do you control your diabetes or does your diabetes control you?" and emphasising that blood glucose monitoring was a tool to help clients gain control.
The programme was successful based on improvements in diabetes management and weight loss in the short term, even though these changes could not be sustained. Additionally, the findings related to client engagement and understandings about diabetes indicate that Te Hauora O Ngati Rarua met the requirements for successful chronic conditions management. The service developed and maintained links with other organisations and professionals ensuring that clients were supported to receive all entitled services. These successes can be attributed to two broad factors - cultural features of the programme that incorporate Maori ways of being, and opportunities for clients to take control and make changes in their lives.
Cultural features of the programme
Many aspects of the programme were consistent with Maori cultural values, including the aim of enabling participants to walk with their grandchildren, which simultaneously focuses on the objective of staying well and mobile, and highlights the importance of whanau and whanaungatanga (Boulton et al., 2013; Public Health Association, 2011). Evidence from clients indicated the programme was culturally appropriate and fitted with their health needs and literacy (Improving Chronic Illness Care, 2008). Health literacy gains included better understanding about food, such as how to interpret labels, the importance of exercise and maintaining overall wellness, such as when to seek help. The delivery of a culturally safe service is important because being comfortable with health services impacts on the use of services, and on health outcomes (Hansen & Cabassa, 2012; Wilson, 2008). The ability of Te Hauora O Ngati Rarua to keep people engaged with the service was therefore a measure of its overall success.
The informal cultural aspects of the programme, such as the sharing of kai, created a sense of community, to bring about change by modelling healthychoicesand creating an environment for discussion and building trust (Fisher, Brownson, O'Toole & Anwuri, 2007). In this programme conversational suggestions and the use of self-deprecating humour by staff was another aspect of keeping people safe; it had a levelling effect in terms of the power differentials amongst people. Staff found individual ways to develop and nurture trusting relationships with clients to facilitate a level of familiarity.
The results support much that is known about Maori attitudes to health, in particular the holistic approach identified in the whare tapa wha model (four-sided house, with wairua, spiritual wellbeing, hinengaro, mental wellbeing, tinana, physical wellbeing and whanau, family wellbeing dimensions) (Durie, 1998) and having a 'wellness' rather than 'illness' approach to health (Dyall, Kerse, Hayman & Keeling, 2011). Providing a "diabetes whanau" by mixing clients of different ages and stages of diabetes in the education courses was generally beneficial, but didn't work so well for the younger clients. The tendency of some clients to use improving health as motivation and becoming discouraged by talk of complications confirmed the benefits of the wellness approach, which might also explain the difficulty some clients had in accepting their diagnosis. The study confirmed the importance of personal commitment when making change, but also identified a range of external motivators that could be called upon, particularly ways the change would benefit whanau.
There were many examples of goodwill and commitment, or going beyond what was required in the contract from the staff, especially in the way they delivered the programme and the lengths they went to keep clients engaged. Boulton (2007) identified and referred to this extra work as the "invisible" Maori aspects of a service. She grouped these aspects as: work to deliver what was perceived to be a culturally appropriate service; work done out of a sense of duty to the client; and work done to improve service resources or staff capabilities. There was a time commitment involved in managing such complex relationships and cultural expectations that the organisation was not reimbursed for; an issue which Boulton (2007) and Boulton et al. (2013) also noted.
Taking control and the difficulties of making and sustaining change
Before people can take control and make change, they have to accept the diagnosis of diabetes (Smide & Hornsten, 2009); this acceptance was not consistently achieved by some clients. Their tendency to identify factors such as stress and genetic links as being responsible for the onset of their condition seemed to contribute to this. Penney, McCreanor, and Barnes (2006) caution that such beliefs related to the onset of disease can lead to hopelessness and disempowerment.
A key revelation was that for several clients diabetes was the least of their problems, other co-morbidities were more problematic. Simmons et al. (2007) also found that clients identified co-morbidities as their second largest barrier to making successful change. Among these, untreated depression (more prevalent among Maori than non-Maori) appeared particularly debilitating (Thomas, Arlidge, Arroll & Elder, 2010). Depression is known to lower clients' motivation, quality of life and self-efficacy to manage their diabetes and make lifestyle change (Ali et al., 2010; Egede & Hernandez-Tejada, 2013). These authors conclude that more aggressive management of depression, with a combination of anti-depressants and/or psychotherapy and diabetes self-management education would improve their physical and mental health.
Four clients demonstrated significantly improved physiological outcome measures during periods of focused lifestyle change, illustrating that it is an achievable objective. Generally though, clients were unable to maintain this progress long-term, especially when they were receiving less input and self-management support. These findings are consistent with those of other authors who have concluded that on-going professional and peer group support is important (Ali, Echouffo-Tcheugui & Williamson, 2012). How to balance on-going support with an overall objective of client self-management and independence is the challenge.
The Te Hauora O Ngati Rarua programme addressed all six elements of the Chronic Care Model, and is viewed as successful, even though short-term improvement in the health status of clients was generally not sustained over the length of the study. The nurse-led service met a need for Maori clients that was not available in other services. The combination of cultural values and practices and the personal qualities of the staff members were valued by the clients of the service. The nature of the interpersonal relationships, especially the use of humour enabled staff to give clients a serious message in a light-hearted, friendly manner and to suggest and role-model healthy choices. Staff demonstrated high levels of goodwill and commitment to the service, with an important result being the ability to keep clients engaged, even when they were not ready to commit to lifestyle change.
The study found that Maori with diabetes can make significant change and have improvements in physiological measures when they are committed and believe that change is important. It also indicates that the balance between providing professional support and withdrawing to encourage independence is difficult to achieve. Kaupapa Maori nurse-led health services have a special place within the NZ health system, because Maori clients do develop a unique understanding and rapport with Maori health staff. Such services deliver care that is proactive rather than reactive, providing continuity and helping people self-manage in the community, thus reducing their need to access secondary services.
Relevance To Clinical Practice
Relationships between staff and clients are important, and include the use of humour and informal relationships to role-model desirable lifestyle behaviour, and to give health information. Co-morbidities such as depression must be managed before clients can be expected to make lifestyle change. By ensuring the environment is comfortable, non-threatening and that there is a sense of community, clients are more inclined to remain engaged with the service even if they are not quite ready to make a change. As part of the current chronic care approach if nurses are to better meet the needs of Maori, nurses need to utilise the whanaungatanga and whanau approach and incorporate hui, karakia, waiata and sharing kai as part of practice. Finally, it is important that nurses recognise people do not always make progress in a linear fashion, use of a stage-based change model that recognises this may help to guide care.
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Josephine Janssen, MN, PGCert, BN, RGON, Nursing Tutor, Nelson Marlborough Institute of Technology, Blenheim, NZ
Katherine Nelson, PhD, RN, Senior Lecturer, Victoria University, Wellington, NZ
Janssen, J., & Nelson, K. (2014). Meeting the needs of Maori with diabetes: Evaluation of a nurse-led service. Nursing Praxis in New Zealand, 30(3), 6-18.
Table 1. Characteristics and Diabetes Status of Study Clients Demographics No. Characteristic No. Gender Female 6 Type 2 Diabetes Yes 5 Male 1 No 1 Pre diabetic 1 Age 17-30 1 Metabolic Yes 5 31-45 1 syndrome No 2 46-65 4 65-75 1 BMI 30.00 -34.99 2 Insulin Yes 2 35.00 -39.99 1 No 3 [greater than or equal to ]40.00 4 During 2 study Metformin Yes 4 No 3 Table 2. Summary of Elements of the Chronic Care Model Element Criteria 1 The community * Encourage patient participation in community programmes * Form partnerships and develop interventions with community organisations * Advocate for policies to improve patient care 2 Health system * Systematically support quality improvement at all levels of the organisation * Develop agreements to co-ordinate care across organisations 3 Delivery system design * Define roles and distribute tasks among team members * Provide clinical case management for complex patients * Ensure regular follow-up * Give care that patients understand and that fits with their cultural background 4 Decision support * Embed evidence-based guidelines into daily clinical practice * Share evidence-based guidelines with patients * Use proven provider education methods * Integrate specialist expertise and primary care 5 Clinical information systems * Provide timely reminders for providers and patients * Identify relevant sub-populations for proactive care * Facilitate individual patient planning * Monitor performance of the practice team and care system 6 Self-management support * Emphasise the patient's central role in managing their health * Includes assessment, goal-setting, action planning, problem- solving and follow-up * Organise internal and community resources to provide self- management support to patients Note: Adapted from Wagner et al (2001).
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|Author:||Janssen, Josephine; Nelson, Katherine|
|Publication:||Nursing Praxis in New Zealand|
|Date:||Nov 1, 2014|
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