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1 A Study of Chief Nurse Executives Indicates Low Prioritization of Evidence-Based Practice and Shortcomings in Hospital Performance Metrics Across the United States Bernadette Mazurek Melnyk, RN, PhD, FNAP, FAANP, FAAN Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC Bindu Koshy Thomas, MEd, MS Michelle Troseth, RN, MSN, DPNAP, FAAN Kathy Wyngarden, RN, MSN, FNP Laura Szalacha, EdD Keywords evidence-based practice, chief nurse, nurse executive, performance metrics, health care ABSTRACT Background: Although findings from studies indicate that evidence-based practice (EBP) results in high-quality care, improved patient outcomes, and lower costs, it is not consistently implemented by healthcare systems across the United States and globe. Aims: The purpose of this study was to describe: (a) the EBP beliefs and level of EBP implementation by chief nurse executives (CNEs), (b) CNEs perception of their hospitals EBP organizational culture, (c) CNEs top priorities, (d) amount of budget invested in EBP, and (e) hospital performance metrics. Methods: A descriptive survey was conducted. Two-hundred-seventy-six CNEs across the United States participated in the survey. Valid and reliable measures included the EBP Beliefs scale, the EBP Implementation scale, and the Organizational Culture and Readiness scale for EBP. The Centers for Medicare and Medicaid Services Core Measures and the National Database of Nursing Quality Indicators (NDNQI) were also collected. Results: Data from this survey revealed that implementation of EBP in the practices of CNEs and their hospitals is relatively low. More than one-third of the hospitals are not meeting NDNQI performance metrics and almost one-third of the hospitals are above national core measures benchmarks, such as falls and pressure ulcers. Linking Evidence to Action: Although CNEs believe that EBP results in high-quality care, it is ranked as a low priority with little budget allocation. These findings provide a plausible explanation for shortcomings in key hospital performance metrics. To achieve higher healthcare quality and safety along with decreased costs, CNEs and hospital administrators need to invest in providing resources and an evidence-based culture so that clinicians can routinely implement EBP as the foundation of care. INTRODUCTION The evidence is irrefutable: findings from multiple studies indicate that evidence-based practice (EBP), compared to care that is steeped in tradition, leads to: (a) a higher quality and reliability of health care, (b) improved population health and patient outcomes, including the patient care experience, and (c) reduced costs, now referred to as the Triple Aim in health care in the United States (Fielding & Briss, 2006; McGinty & Anderson, 2008; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Despite findings from research supporting the benefits of evidence-based care and its emphasis in the Affordable Care Act, it is not the standard of practice implemented by many clinicians and healthcare systems across the United States and the globe due to multiple barriers that continue to be a deterrent to the translation of research findings into real-world practice settings (Fink, Thompson, & Bonnes, 2005; Harding, Porter, Horne-Thompson, Donley, & Taylor, 2014; Melnyk, Fineout- Overholt et al., 2012). Among these barriers are: (a) inadequate knowledge and skills in EBP by clinicians, (b) lack of EBP mentors and practice facilitators, (c) misconceptions that EBP takes too much time, (d) cultures and environments that do not support EBP, (e) inadequate resources, and (f) lack of expectations and organizational mandates to implement evidencebased care (Harding et al., 2014; Melnyk, Fineout-Overholt et al., 2012; Melnyk et al., 2012; Nagykaldi, Mold, Robinson, Niebauer, & Ford, 2006). Therefore, it is doubtful that the goal 6 Worldviews on Evidence-Based Nursing, 2016; 13:1, 6 14.

2 set by the Institute of Medicine (IOM) that 90% of healthcare decisions will be evidence-based by 2020 will be achieved unless urgent action is taken to transform current healthcare systems across the United States (2008). EBP is a problem-solving approach to clinical decisionmaking in health care that integrates the best evidence from well-designed studies with a clinician s expertise, which includes internal evidence from patient assessments and practice data, and a patient s preferences and values (Melnyk & Fineout- Overholt, 2015). In the landmark summit sponsored by the IOM on health professions education, it was recommended that all health professional educational programs should include five competencies, including: (a) providing patient centered care, (b) applying quality improvement principles, (c) working in interprofessional teams, (d) using EBPs, and (e) using health information technologies (IOM, 2003). However, challenges remain in the teaching of EBP in academic programs throughout the United States as many faculty continue to teach health sciences students the rigorous process of how to conduct research instead of how to use research and consistently implement evidence-based care (Melnyk, 2013). In a national survey by Melnyk et al. (2012) with a random sample of over 1,000 nurses who were members of the American Nurses Association, 74% of the respondents indicated the need for additional education in EBP. Nurses in this survey also indicated the persistence of many of the same EBP barriers that have been reported for decades (e.g., lack of time, organizational culture, inadequate EBP knowledge and skills). However, one new barrier was identified that had not been previously reported in the literature: manager and leader resistance to EBP. Respondents to the national survey expressed a need for support from their leaders, managers, and interdisciplinary colleagues in order to be able to implement EBP. The literature has revealed that leaders who create a vision for EBP in their organization provide resources to support it and incorporate evidence into their own leadership practices, thus having a key influence on the implementation of evidencebased care (Melnyk & Fineout-Overholt, 2015; Rycroft-Malone, 2008). Although findings from a prior study indicated that Chief Nursing Officers (CNOs) and Chief Nursing Executives (CNEs) often believe in the value of evidence-based care, their own implementation of EBP is low (Sredl et al., 2011). In addition to these known challenges related to leadership and EBP, there are major gaps in the literature regarding how nursing leaders prioritize EBP and the extent to which they invest in it. Therefore, a national (US) survey was conducted with CNEs and CNOs throughout the nation to: (a) fill this knowledge gap, (b) assess their EBP beliefs and level of EBP implementation, (c) evaluate their perceptions of organizational culture and environment for EBP, and (d) describe performance metrics in their healthcare systems. Data from this survey were also intended to inform appropriate next steps in working with CNEs and CNOs across the United States to advance and sustain EBP in their healthcare systems to ultimately improve patient care and outcomes. METHODS The study was an anonymous online survey of CNEs and CNOs throughout the United States granted exempt status by the first author s institutional review board. Elsevier provided an list of 5,100 CNOs and CNEs, and an was sent to all of them with an invitation to complete the anonymous survey. Participants were provided a cover letter with a description of the study. The provided a link to the survey. A reminder was sent 1 week following the first contact and another reminder was sent 1 day before the survey closed. The survey participants were offered an incentive to participate in the study; an opportunity to enter a drawing for 1 of 10 $100 gift cards. The gift card recipients were determined using a computer-generated random number list. The recipients received their gift card after the survey closed. Measures Data collected on the survey included: (a) demographic questions; (b) three valid and reliable instruments that measured beliefs about EBP, EBP implementation, and perceived organizational culture of EBP; (c) CNE and CNO priorities and budget investment in EBP, and (d) CMS Core Measures and National Database of Nursing Quality Indicators (NDNQI) measures. EBP beliefs were measured with the EBP Beliefs (EBPB) scale, which taps beliefs about the value of EBP and the ability to implement it (Melnyk, Fineout-Overholt, & Mays, 2008). This is a 16-item Likert-type scale ranging from 1 (strongly disagree) to5(strongly agree). Sample items include: I am clear about the steps in EBP, I am sure that I can implement EBP, and I am sure that evidence-based guidelines can improve care. The summed total EBP score with higher scores indicate stronger EBP beliefs. The EBPB scale has established face, content, and construct validity, with internal consistency reliabilities typically above 0.85 (Melnyk et al., 2008). Implementation of EBP was measured with the EBP Implementation (EBPI) scale (Melnyk et al., 2008), which assessed the extent to which the CNEs and CNOs implemented EBP. Participants respond to 18-item Likert-type scale items by answering how often in the last 8 weeks they have performed certain EBP tasks, including: (a) generated a PICO question about my practice, (b) used evidence to change my clinical practice, and (c) shared outcome data collected with colleagues. Item scores are summed for a total score range from 0 to 72, with higher scores indicating greater implementation of EBP. The EBPI has established face, content, and construct validity with internal consistency reliabilities reported at above 0.85 (Melnyk et al., 2008). Organizational culture was measured with the Organizational Culture and Readiness for System-Wide Integration of EBP (OCRSIEP) scale, which taps organizational culture and readiness for EBP (Fineout-Overholt & Melnyk, 2003). This instrument measures the extent to which cultural factors that influence system-wide implementation of EBP exist in the environment and the overall perceived readiness for integration Worldviews on Evidence-Based Nursing, 2016; 13:1,

3 CNE Study: EBP & Performance Metrics of EBP and how it compares to 6 months ago. Respondents are asked to indicate their agreement with each item on a 5-point Likert-type scale, with 1 meaning none at all and 5 meaning very much. Examples of items on the 26-item scale include: (a) To what extent is EBP clearly described as central to the mission and philosophy of your institution? and (b) To what extent do you believe that EBP is practiced in your institution? Items are summed to create a total score, ranging from 25 to 125, with higher scores reflecting greater organizational readiness for and movement toward a culture of EBP. The scale has established face and content validity, with internal consistency reliabilities reported at above 0.85 (Melnyk, Fineout-Overholt, Giggleman, & Cruz, 2010). CNE priorities and budget investment in EBP were assessed with the following questions: (a) As a CNE, what are the top three priorities that you are currently focused on in your role? and (b) What percent of your annual operating budget do you spend on building and sustaining EBP in your organization? Data on core performance measures were gathered with the following question: In your most recent core measures report, at which level did your nursing unit perform in the following nurse-related measurements (e.g., catheter-associated urinary tract infections, pressure ulcer stage III and IV, vascular catheter-associated infections)? Response choices included below national rate, same as national rate, and above national rate. Data on NDNQI measures were assessed with the following question: In your most recent NDNQI report, at which level did your nursing department perform on the following nurse sensitive indicators (e.g., falls, falls with injury, hospital-acquired pressure ulcers). Response choices included below benchmark, at benchmark, and exceeding benchmark. DATA ANALYSIS Because this was a descriptive national survey, descriptive statistics (e.g., means, standard deviations, and percentages) were conducted on the study s variables. Cronbach alphas were computed on the EBP scales used. Prior to beginning the study, a decision was made to only include data on fully completed surveys in the analysis. RESULTS A convenience sample of 5,100 s from a data base of CNEs and CNOs from Elsevier were disseminated, and 1,199 (24%) were returned as undeliverable. Therefore, the actual sample comprised 3,901 CNEs and CNOs. Although 327 CNEs and CNOs started the survey (8%), it was fully completed by 276 (a 7% response rate) who were from 45 states in the United States and the District of Columbia. Ninety-three percent of the respondents were currently in the chief nurse role and were an average of 55 years of age. The majority were white and female, with over two-thirds having a master s degree as their highest level of education (Table 1). Sixty-eight percent of the hospitals had less than 301 beds and 18% had Mag- Table 1. CNO and CNE & Organizational Demographics CNO/CNE Demographic Data Gender Frequency Percent Male 21 8% Female % Ethnicity American Indian 2 1% Asian 4 1% African American 10 4% White % Education Diploma 4 1% Associate s degree 5 2% Bachelor s degree 17 6% Master s degree % PhD 22 8% DNP 29 10% Other 10 4% Currently CNO/CNE Yes % No 21 7% Age Minimum Maximum Average Organizational data Size Percent Fewer than 100 beds 37% beds 31% beds 14% beds 9% 801-1,000 beds 4% Greater than 1,000 beds 4% Other 1% Magnet designated Yes 18% No 82% BSN preparation Less than 25% 26% (Continued) 8 Worldviews on Evidence-Based Nursing, 2016; 13:1, 6 14.

4 Table 1. Continued CNO/CNE Demographic Data Frequency Percent 26-50% 42% 51-75% 26% % 6% Nursing satisfaction Very dissatisfied 1% Somewhat dissatisfied 11% Somewhat satisfied 62% Satisfied 26% net status designation, which is a credential awarded by the American Nurses Credentialing Center to healthcare organizations for quality patient care, nursing excellence, and innovations in nursing practice. More than two-thirds of the hospitals (n = 188) had less than 51% baccalaureate prepared nurses. Sixty-two percent (n = 172) of the CNEs and CNOs reported that their nurses were somewhat satisfied with only 73 CNEs and CNOs (26%) reporting that their nurses were satisfied on their nurse satisfaction surveys (Table 1). Although the CNOs and CNEs beliefs about the value of EBP were high (Table 2), approximately 25% were not clear about the steps of EBP and nearly 44% reported that they were not sure they could implement EBP in a time efficient manner. More than 50% of CNEs and CNOs believed that EBP is practiced in their organization from not at all to somewhat. Furthermore, 48% of the chief nurses reported that they were unsure of how to measure the outcomes of services delivered to patients. The CNEs and CNOs own implementation of EBP was low (Table 2). Specifically, over half of the CNEs and CNOs reported that they had not accessed important databases for evidencebased guidelines or systematic reviews of evidence during the past 8 weeks. Organizational culture and readiness for EBP across the hospitals was low to moderate (Table 2). Specifically, nearly 60% of the chief nurses reported they believed EBP is practiced in their organizations not at all to somewhat. In response to the question, compared to 6 months ago, how much movement in your organization has there been toward EBP culture? 52% of the chief nurses said not at all to somewhat. In response to the question on the EBP culture scale regarding to what extent fiscal resources were used to support EBP, 72% of the respondents said not at all to somewhat. Regarding performance metrics, the chief nurses reported that more than one-third of their hospitals are not meeting benchmarks for NDNQI measures (Figure 1), and almost onethird of the hospitals are above national benchmarks for core measures (e.g., falls, pressure ulcers; Figure 2). The top priorities as stated by the chief nurses were quality and safety, yet EBP was cited as a top priority for only 3% of the chief nurses (Figure 3). Regarding budget, 74% of the CNOs and CNEs invested only 0% to 10% of their annual operating budgets on building and sustaining EBP in their organizations. DISCUSSION The results of this survey indicate that, although the CNEs and CNOs reported that they believe in the value of EBP, their own implementation of EBP is relatively low. More than half of the CNEs and CNOs also reported that there is a low level of evidence-based care practiced in their organizations. This low level of EBP can be partially explained because the majority of hospitals had less than a 51% baccalaureate prepared workforce and only 18% of the hospitals had achieved Magnet status. In the United States, research has supported that hospital outcomes (e.g., lower mortality and failure to rescue rates) are better with baccalaureate prepared nurses and they exhibit higher levels of EBP than nonbaccalaureate prepared nurses (Aiken, Clarke, & Cheung, Sloane, & Silber, 2003; Wilson et al., 2015), which is the impetus for the IOM recommendation that 80% of nurses in the United States are baccalaureate prepared by 2020 (IOM, 2011). Furthermore, a recent study of 136 Pennsylvania hospitals (11 emerging Magnets and 125 non-magnets) indicated that Magnet recognition is associated with significant improvements over time in quality of the organization s work environment as well as patient and nursing outcomes that exceed those of non-magnet hospitals, including fewer deaths per 1,000 patients (Kutney-Lee et al., 2015). Although the CNEs and CNOs stated that their highest priorities were quality and safety, EBP was not listed as a top priority and very little of their budgets were allocated to implementing and sustaining evidence-based care. These findings provide another explanation for the shortcomings revealed in core performance and NDNQI metrics in a substantial portion of the hospitals. The findings also indicate a disconnection or lack of understanding by chief nurses that EBP is a key driver to achieving quality and safety in health care. Without a prioritization on EBP and necessary investment in an infrastructure to sustain it by CNEs and CNOs and chief executive officers, key quality and safety outcomes in healthcare systems are unlikely to be achieved. In order for the Triple Aim to be reached in the US healthcare system, EBP needs to be the foundation of care delivered by all healthcare professionals across disciplines, using an interprofessional team-based model of care. However, the literature abounds with studies that indicate this type of practice is far from reality. Findings from research have indicated that, although health professionals from a variety of disciplines believe in the benefits of EBP, only a small percentage consistently use this approach in caring for their patients (Harding et al., 2014; Melnyk, Fineout-Overholt et al., 2012; Melnyk et al., 2012). In Worldviews on Evidence-Based Nursing, 2016; 13:1,

5 CNE Study: EBP & Performance Metrics Table 2. CNO/CNE Scores on EBP Scales Minimum Maximum Possible Possible Standard Score Score Mean Deviation EBPB scale EBPI scale Organizational culture & readiness scale % 50% Below benchmark At benchmark Exceeding benchmark 40% 30% 20% 10% 0% Falls Falls with injury Pressure ulcers Pressure ulcers (Stage 2 and above) Restraints Nursing care hours RN education RN certification Figure 1. NDNQI Metrics. a recent study, Harding and colleagues (2014) found that both clinicians and managers did not view EBP as a core component of clinical care because higher priorities took precedent (e.g., maintaining patient flow). Although nurse executive leadership competencies include the implementation and sustainability of evidence-based improvements in quality and costs, including creating structures to ensure access to information, resources, and support (American Organization of Nurse Executives, 2004; Everett & Sitterding, 2011), this study reflects that these executive activities are not routinely occurring in real-world clinical organizations. Nurse executives must be provided with the knowledge that EBP should be the consistent foundation of care delivery because it is linked to improved outcomes, which are measurable and meaningful returns on the investment in EBP. This knowledge would assist chief nurses in understanding the value of allocating more of their budgets to creating an infrastructure to support and sustain EBP. Nurse executives also must be actively engaged in EBP in their own decision making and role model it for their directors, managers, and point of care staff as prior research has indicated that role modeling and valuing of research by nursing management increases the use of evidence in practice (Gifford, Davies, Edwards, Griffin, & Lybanon, 2007). It is critical for nursing and other interprofessional healthcare executives to build a culture and environment that supports the implementation and sustainability of evidence-based care in order to achieve best outcomes, which includes the provision of necessary EBP resources and tools (Melnyk, 2014a; Rycroft-Malone et al., 2013). Organizations need to provide evidence that their policies and procedures are based upon the best evidence and that clinicians are provided with rigorous evidence-based guidelines and mechanisms to support their implementation. Evidence-based councils comprised of 10 Worldviews on Evidence-Based Nursing, 2016; 13:1, 6 14.

6 60% 50% Below national rate Same as national rate Above national rate 40% 30% 20% 10% 0% Catheter associated urinary tract infections Pressure ulcers (Stage 3 and 4) Vascular catheter associated infections Falls and trauma Manifestations of poor glycemic control Figure 2. Core Measures. 25% 20% 15% 10% 5% 0% Quality Patient safety Benchmarks Finance Recruitment and retention Staffing Patient satisfaction Vision/culture Evidence-based practice Summarized from the survey question: As a CNO/CNE, what are the top 3 priorities that you are currently focused on in your role? Figure 3. CNO/CNE Top Priorities. transdisciplinary clinicians also can be instrumental for enhancing EBP throughout the organization through an interprofessional team-based approach, which has been supported to lead to a higher quality of care. Research supports that transdisciplinary teamwork leads to a higher quality of care and better patient outcomes (Raab, Will, Richards, & O Mara, 2013). Furthermore, time must be allocated for clinicians to engage in the EBP process. The time invested in EBP should be promoted as essential and valuable as opposed to being labeled as nonproductive time as is the case in many hospitals across the United States (Melnyk, 2014a). It is not enough to disseminate evidence-based guidelines and expect clinicians to readily implement them. For many clinicians, EBP requires behavior change from practice steeped in tradition and organizational cultures of this is the way we do it here to practice that is supported by science. Behavior Worldviews on Evidence-Based Nursing, 2016; 13:1,

7 CNE Study: EBP & Performance Metrics change in clinicians cannot be achieved by the provision of information alone; often it is precipitated by an emotional reason to change (e.g., a compelling story) along with educational and skill-building workshops to learn the EBP process (Melnyk, 2014a). Transformation to an EBP culture also requires an exciting team vision and clear expectations from healthcare leaders that EBP is the foundation of all care delivered within the healthcare system. This expectation should be integrated into the vision, mission, and strategic plan of the institution and incorporated into the onboarding of all new clinicians. Furthermore, nurses should be expected to achieve the new EBP competencies for practicing nurses and advanced practice nurses within their organizations (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014), which means that baccalaureate and associate degree academic programs must teach their students EBP, not the complex process of how to conduct rigorous research. For those clinicians who fall short on some of the competencies at the start of their employment, continuing education workshops with skill-building activities should be provided until full competence is achieved. Integration of these EBP competencies into job descriptions and clinical ladder promotion systems can also establish clarity of performance expectations and serve as an incentive for clinicians to attain them. A critical mass of EBP mentors also should be made available to point of care clinicians throughout healthcare systems as research has indicated that they facilitate evidence-based care and improve patient outcomes (Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Melnyk, 2007; Wallen et al., 2010). These mentors should document the so what outcomes (i.e., outcomes that the current healthcare system is most focused on, including cost, complications, length of stay, and rehospitalizations) to support the benefits of their work (Melnyk, 2014b). As a follow-up to our national survey of nurse executives, a national forum with over 150 CNEs and CNOs throughout the country was held at the 2014 national conference of the American Organization of Nurse Executives. The purpose of this national forum was to share the findings from the recent survey and generate solutions to assist nurse executives with improving their own EBP skills along with determining the best resources and tools to help them to build strong EBP cultures and environments within their own hospitals and healthcare systems. The nurse executives at the national forum called for a bridging of the knowledge gap between EBP and healthcare quality and patient safety as well as the need for educational offerings, specifically for them, to enhance their own knowledge and skills in EBP and assist them in creating stronger cultures and environments for EBP. They emphasized that it is critical for nurse executives and other healthcare administrators to be helped to understand the gap between EBP and its impact on clinical outcomes and return on investment (ROI). Limitations to this study include a convenience sample and low response rate, which decreases generalizability of the findings. In addition, the survey was a single snapshot of the state of care and outcomes in hospitals across the United States along with self-reported data by the CNEs and CNOs. Future research is needed that gathers objective data over time along with selfreported data and measures that tap EBP and investments in evidence-based care. Although there has been progress in EBP over the past decade, there is much to be accomplished yet. In efforts to speed the translation of research into real-world clinical settings, it is critical to focus on nurse executives as they have important influence over the clinical enterprise and budgetary responsibility for nurses within their healthcare systems. Chief executive officers and other healthcare administrators also must understand the link between EBP and improved healthcare system outcomes. They must be assisted in understanding and valuing the importance of EBP in reaching their high-priority goals of healthcare quality and safety. Only through accelerated efforts in working with executives to build cultures and environments that support EBP and intensive skill building with point of care transdisciplinary clinicians will EBP become the foundation for high-quality, safe, and cost-effective care throughout the United States healthcare system and the globe. WVN LINKING EVIDENCE TO ACTION Findings from this national survey indicate that CNEs and CNOs need education and skill building in EBP and outcomes management so that they themselves implement and role model EBP. Evidence regarding ROI with EBP is necessary so that chief nurses and hospital administrators realize that healthcare outcomes are improved and cost savings are generated with EBP, and that it is key to quality and safety. CNEs and CNOs and healthcare administrators need to build cultures and environments that promote and sustain EBP, which requires financial investment. Healthcare systems need to provide support for their nurses to obtain baccalaureate degrees and be encouraged to embark on the Magnet journey. The new EBP competencies for practicing nurses and advanced practice nurses need to be integrated into job descriptions and organizational expectations. All associate degree and baccalaureate nursing programs need to prepare their students to meet the new EBP competencies for practicing nurses and graduate nursing programs should prepare their students to meet the EBP competencies for advanced practice nurses. 12 Worldviews on Evidence-Based Nursing, 2016; 13:1, 6 14.

8 Author information Bernadette Mazurek Melnyk, Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor, College of Nursing, Professor of Pediatrics and Psychiatry, College of Medicine, The Ohio State University, Columbus, OH, USA; Lynn Gallagher-Ford, Director, Center for Transdisciplinary Evidence-Based Practice, Clinical Associate Professor, The Ohio State University, College of Nursing, Columbus, OH, USA; Bindu Koshy Thomas, Technology Coordinator, Center for Transdisciplinary Evidence-Based Practice, The Ohio State University, College of Nursing, Columbus, OH, USA; Michelle Troseth, Chief Professional Practice Officer, Elsevier Clinical Solutions, Grand Rapids, MI, USA; Kathy Wyngarden, Manager, Elsevier CPM Consortium, Elsevier Clinical Solutions, Grand Rapids, MI, USA; Laura Szalacha, Director of Research Methods and Statistics, University of Arizona College of Nursing, Tucson, AZ, USA Funding for this project was provided by Elsevier Clinical Solutions Address correspondence to Dr. Bernadette Mazurek Melnyk, The Ohio State University, 1585 Neil Avenue, Columbus, OH 43210; Accepted 4 August 2015 Copyright C 2016, Sigma Theta Tau International References Aiken, L. 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