Measuring the Dose of Nursing Intervention

International Journal of Nursing Terminologies and Classifications Volume 18, No. 4, October-December, 2007 121

Blackwell Publishing IncMalden, USAIJNTInternational Journal of Nursing Terminologies and Classifications1541-5147XXX Original Articles

Measuring the Dose of Nursing Intervention


David Reed, PhD, Marita G. Titler, PhD, RN, FAAN, Joanne M. Dochterman, PhD, RN, FAAN, Leah L. Shever, PhD(c), RN, Mary Kanak, PhD, RN, and Debra M. Picone, PhD, RN

PURPOSE.

To increase awareness of the many

issues involved in measuring the dose of nursing

intervention in nursing interventions

effectiveness research.

METHODS.

Identify critical issues in measurement

of the dose of nursing intervention and discuss

decisions regarding dosage measurement made in

a study of the effectiveness of nursing

interventions.

FINDINGS.

A single method can be applied to

resolve two critical issues in intervention dosage

measurement.

CONCLUSIONS.

Those conducting nursing

interventions effectiveness research must think

explicitly about how intervention dosage will be

measured and reported so that dosage can be

replicated in research and practice.

PRACTICE IMPLICATIONS

. Measuring and

reporting the dose of nursing intervention in

research is essential to the development of an

evidence base adequate to support practice.

Search terms

:

Nursing interventions, dose of

nursing treatment, effectiveness research

David Reed, PhD, is Statistician for the Office for Nursing Research and the Interventions and Outcomes Project, University of Iowa College of Nursing; Marita G. Titler, PhD, RN, FAAN, is Director of Nursing Research, Quality and Outcomes Management, and Senior Assistant Director, University of Iowa Hospitals and Clinics; Joanne M. Dochterman, PhD, RN, FAAN, is Professor Emeritus, University of Iowa College of Nursing; Leah L. Shever, PhD(c), RN, is Project Director of the Nursing Interventions and Outcomes Effectiveness Grant, University of Iowa College of Nursing; Mary Kanak, PhD, RN, is Quality Management Specialist, Mercy Medical Center, Cedar Rapids; and Debra M. Picone, PhD, RN, is in the Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, IA.

Introduction

Recent years have seen considerable emphasis onnursing interventions research (Conn, 2005). Variousauthors have examined the problems in developingrandomized clinical trials of nursing interventions(Fogg & Gross, 2000), called for the testing of nursinginterventions under real world conditions (Dochterman& Bulechek, 2004; Sidani, Epstein, & Moritz, 2003), anddescribed what information about nursing interven-tions clinicians need from researchers (Brown, 2002;Given & Given, 2004). The essential message is the needfor a research base that nurses can use in practice to makewell-grounded decisions about what nursing inter-ventions to provide and how much of each interventionshould be provided to achieve a desired outcome.

To conduct research on the effectiveness of nursinginterventions, it is necessary to construct variablesto represent the interventions. There are, however,important issues concerning how nursing interventionsare represented, and how these issues are resolved canhave substantial implications for what can be learnedfrom nursing interventions research. This article focuseson issues related to representing the dose of nursingintervention in nursing interventions effectiveness

122 International Journal of Nursing Terminologies and Classifications Volume 18, No. 4, October-December, 2007


research, which typically employs large datasetscontaining many nursing intervention variables.

Researchers have been advocating for years for anexplicit description of the dose of nursing intervention(Brooten & Youngblut, 2006; Conn, Rantz, Wipke-Tevis,& Maas, 2001; Huber, Hall, & Vaughn, 2001; Santacroce,Maccarelli, & Grey, 2004; Sidani & Braden, 1998), anddiscussions of research on specific nursing interventionsmention the need for describing the dose of those inter-ventions in research reports (Eller, 1999; Omery, 2003;Smith, Richardson, Hoffman, & Pilkington, 2005; Snyder& Chlan, 1999). Nevertheless, the specification of doseof nursing intervention in nursing effectiveness researchis surprisingly rare. In a review of reports of controlledclinical trials of nursing interventions published in2000–2001, Lindsay (2004) identified lack of explicitinformation on intervention dose to be the biggestproblem, finding that none of 47 reports reviewedprovided sufficient information on dose. We have foundno publications discussing issues of dosage representa-tion in nursing interventions effectiveness research.

Reasons for Measuring the Dose of Nursing Intervention

Questions Requiring Dose Information

The simplest way to represent a nursing inter-vention in a statistical analysis is to create a dichotomousvariable that has one value if the intervention wasprovided and another value if it was not. This method ofrepresentation treats the dose of intervention as equalfor all those who receive an intervention at least onceduring a specified period, and does not consider thefrequency or time period of delivery. Ignoring theseconsiderations may result in a significant loss of infor-mation. Intuitively, one would expect that, in general,the benefit of a nursing intervention would increase asthe amount of intervention delivered increases, eventhough there may be some minimum dose below whichthere is no effect or some maximum dose beyondwhich there is no additional benefit.

In investigations of the effect of pharmaceuticalinterventions, this is referred to as the

dose–responserelationship

(Berry, 1999), and the existence of such arelationship is a basic assumption in all investigationsof the effect of pharmaceutical interventions. The fourfundamental questions to be asked in an investigationof a pharmaceutical intervention were listed by Ruberg(1995): (a) Is there any evidence of a drug effect? (b)Which doses exhibit a response different from thecontrol response? (c) What is the nature of the dose–response relationship? (d) Which is the optimal dose? Ofthese four questions, three of them concern variationin the dose.

Research Needs

Furthermore, even the answer to the first questioncan be put into doubt by failure to adequately representthe dose of intervention. Failure to clearly representdose in nursing interventions research can result infailure to maintain intervention fidelity. Intervention,or treatment, fidelity (Resnick et al., 2005; Santacroceet al., 2004) refers to consistency in carrying out an inter-vention repeatedly. Specifying the dose of nursingintervention is not sufficient to guarantee interventionfidelity—one must reproduce

what

was done and

who

did it as well—but it is necessary for interventionfidelity. If, in a study of a nursing intervention, thedose varies, but the researcher is not aware of it, anincorrect conclusion might be reached about the effectof the intervention. Failure to detect an interventioneffect might result, not because the intervention wasactually ineffective, but because the dose of interven-tion needed to produce an effect was not maintainedthroughout the course of the study.

Practice Needs

Information about the dose of a nursing inter-vention that has been found to be effective throughresearch is also important for nurse clinicians who wantto engage in evidence-based practice. The recent research


focus on nursing interventions is directed at more thanjust obtaining evidence of the effectiveness of nursinginterventions. The ultimate purpose is to see effectiveinterventions put into practice (Shapiro & Driever,2004; Titler et al., 2001; Yoder, 2005). Clinicians cannotbe assured that they are practicing evidence-basedcare without explicit information on the effectivedosage.

Administrative Needs

From an administrator’s perspective, specificationof dose creates the possibility of maximizing benefitsfrom nursing interventions while minimizing costs.Consider the second of Ruberg’s questions, “Whichdose exhibits a response different than the controlresponse?” If the nurses on a unit are delivering alower dose of intervention than the amount needed toachieve a desired effect, then the time and effort on thepart of the nurses to provide the intervention wouldbe wasted because it would produce no benefit. Onthe other hand, if nurses are delivering a larger dosethan necessary to produce the desired effect, thatwould also mean that time and effort were beingwasted. Investigations of the effects of nursing inter-ventions on outcomes that examine dose–responserelationships can provide administrators with theinformation they need to ensure that adequate, butno more than necessary, resources are expended toproduce the desired response.

Challenges in Measuring the Dose of Nursing Intervention

A Nursing Interventions Effectiveness Study

Recognizing that it is desirable to measure the dosein nursing interventions effectiveness research is onlythe beginning. There is still the challenge of operation-alizing the dose of nursing interventions. The issues inmeasuring nursing interventions must be clarified andmeans devised to resolve those issues. In the following,

we use our own experience in an effectiveness studyof nursing interventions to raise some of the issuesand present solutions for them.

The study, funded by the National Institute ofNursing Research (NINR) (RO1 NR05331, PI-Titler), isone of the first to conduct nursing outcomes effective-ness research using existing clinical and operationaldata that reside in several electronic data repositories.The study examines the relationships between nursinginterventions and several outcome measures for threedifferent patient populations.

The site for this research was one of the first facilitiesin the United States to implement the Nursing Inter-ventions Classification (NIC) (Dochterman & Bulechek,2004) using an electronic documentation system. Theuse of a standardized language to describe nursing inter-ventions greatly facilitates the process of representingdose of nursing intervention in outcomes effectivenessresearch (Bakken et al., 2005). Furthermore, use of astandardized nursing language facilitates interventionfidelity and replication across settings.

Components of Dose

Definitions

Sidani and Braden (1998) identified three com-ponents of dosage of nursing interventions: amount,frequency, and duration.

Amount

is the quantity ofnursing intervention delivered at one point in time.It might also be described as the strength of a singleunit of intervention delivered.

Frequency

is the numberof times the intervention is delivered over a specifiedtime period.

Duration

is the entire length of time overwhich the intervention is delivered.

Multiplying the amount of the intervention by thefrequency of intervention produces a rate, the quantityof nursing intervention per time period, or what wehave called the

nursing intervention use rate

. In thefollowing paragraphs we discuss how amount andfrequency were operationally defined in our study toconstruct a nursing intervention use rate, and then weexamine how duration may be operationally defined.



Amount

The amount of an intervention is calculated bycounting the units of intervention delivered. Fornursing interventions, the definition of the unit ofintervention is generally not as straightforward as thedefinition for pharmaceutical treatments. How theunit of intervention is defined can impact the findingsof effectiveness studies, because changes in the unit ofintervention could result in different relative valuesamong cases.

As stated, NIC language was used to documentnursing interventions in the data for our study. InNIC, each nursing intervention has a label and adefinition at a conceptual level. For example, the NICintervention with the label Surveillance is defined as“purposeful and ongoing acquisition, interpretation,and synthesis of patient data for clinical decisionmaking” (Dochterman & Bulechek, 2004, p. 687). EachNIC intervention is associated with concrete activitiesthrough which the intervention is carried out. An activityfor Surveillance is, “Ask patient about recent signs,symptoms, or problems” (Dochterman & Bulechek, p. 687).

In the data used for our effectiveness research, it isthe specific nursing activities associated with an inter-vention that are documented at the clinical site. Theseactivities are recorded in the electronic documentationusing codes that identify each specific activity and linkit with an NIC intervention. Each record of an activityis stamped with the date and time when the activitywas performed. Our definition of a unit of inter-vention is a

set

of activities carried out

at the same time

and related to a single intervention. That is, whetherone, or several activities associated with a singleintervention code are carried out at a single point intime, this use of an intervention is counted as one unitof the intervention. This treats one activity as equal instrength to two or more activities, if the two or moreactivities are done at the same time. Although thisdefinition is based on the NIC classification, it couldbe applied to any nursing intervention classificationsystem that associates a set of nursing activities withan individual nursing intervention.

The broad scope of the study was a major factor inthe decision to define the unit of intervention at theNIC label level rather than at the activity level. Evenwhen defined at the label level, there were 182 differentinterventions used in the fall prevention sample ofvisits. Constructing dosage variables and performinganalyses with this many NIC label-level interventionswas a substantial challenge. Constructing and analyzinga much greater number of intervention variables atthe activity level would not have been practical in ourstudy. However, in other studies, with a more narrowfocus, researchers might well want to determine dosageand perform analyses using the activity level.

There are a number of possible methods for calcu-lating the amount of intervention at the NIC labellevel. One possibility is simply counting the numberof activities performed at one time to determine theamount of intervention. Another is to determine thetotal amount of time spent on all activities. Both of theseprocedures treat each activity as being of equal strength,when they may not be, but do allow the amount ofintervention delivered at any one time to vary.

Further granularity could be achieved by weightingeach activity as to its strength so that different activitieswould not contribute equally to the calculation ofthe amount of intervention. Each activity would beassigned a value or weight, and the values would thenbe summed.

We chose the simplest definition of a unit ofintervention at the label level. An intervention wasperformed when one or more activities related to thatsingle NIC label at a single point in time were delivered.The data for this study included millions of records ofactivities reflecting interventions delivered over thecourse of 11,000 hospitalizations, and simplicity hadmuch appeal. With little in the way of an empiricalbasis for weights in the literature, the determination ofweights for a large number of different types of activitieswould be burdensome and difficult. It would require aseparate study to ensure that the weights decidedupon and applied to activities were valid. Withoutinformation on the benefits and drawbacks of the


more complex definitions, we chose not to weight orcount activities in defining a unit of nursing inter-vention at the NIC label level.

Frequency

Selecting a time period for the frequency, whichbecomes the denominator in the calculation of anintervention use rate, can be a choice of what intuitivelyseems appropriate. The unit of time we chose to usewas 24 hr. We were interested in all nursing inter-ventions used during a hospitalization for the patientpopulations included in our study, and no one unit oftime is ideal across all of those nursing interventions.Nursing interventions vary considerably in the numberof times an intervention is repeated. Some, such asSurveillance, may be repeated dozens of times duringa day, while others, such as Bathing, may occur onlyonce a day. Although this makes no overall choice oftime unit entirely satisfactory, in our experience one24-hr day works reasonably well for most inter-ventions, with use rates generally falling within a rangefrom 1 to 10. The number of interventions per day alsoseems to be a measure that practicing RNs would findreadily comprehensible and meaningful.

Duration

In many instances, the actual period of time overwhich an intervention was delivered may not be ameaningful or practical definition of duration for thepurposes of a research project. The choice of the lengthof time that serves as the duration has substantiveimplications for the results obtained from analysis.One choice for duration might result in a finding of norelationship between the dose of an intervention andan outcome of interest while another would result infinding a relationship. The choice of duration willdepend on the question asked, and it may take somethought to determine what duration period is mostappropriate to use for a particular question.

The reasonable choice for the end of the durationperiod would be some time prior to the occurrence ofthe outcome. For example, in an investigation of fall

severity for patients who had had a fall, only the nurs-ing interventions that were delivered before the fallwould be of interest.

For some purposes, it might be desirable to calculatethe nursing intervention use rate for subparts ofthe duration period, such as each individual day of ahospitalization. We have, in fact, used daily nursingintervention use rates to create descriptions of patterns ofNIC interventions over the course of hospitalizations(Dochterman et al., 2005; Shever, Titler, Dochterman, Fei,& Picone, 2007). This choice, too, is a matter of thenature of the problem being investigated and whatquestion is being asked. For example, expert clinicaljudgment might suggest that the timing of a certainintervention, not simply the amount of the inter-vention, mattered in relation to an outcome. Dependingon the research question, it may be important to knowthat an intervention was delivered twice on days 1, 2,and 3 of a hospitalization, but not at all on days 4 and 5,rather than to know that the intervention was deliveredsix times during a hospitalization.

We chose to calculate the average intervention rateover the entire hospitalization as the basic measure.That is, we counted all the times an intervention wasdelivered during the entire hospitalization and dividedthis by the total length of stay (in days) to get anaverage intervention use rate per day over the entirehospitalization (see Table 1 for examples). This choicewas influenced largely by the scope of the study.Because this is a pioneering effort in nursing interven-tions effectiveness research, the research was focusedon obtaining a broad picture, which can then form theframework for more detailed investigations.

Analytical Issues

Even with decisions made about amount, frequency,and duration, there are still other issues to consider,ones that are largely unrecognized in the nursingliterature. These can be expressed in two questions: (a)How should the considerable variation in use ratesamong nursing interventions be handled to facilitate



comparison among interventions in their effects onoutcomes? (b) How should uncertainty about the formof the relationship between interventions and outcomesbe handled, i.e., is the relationship linear or not?

For both of these issues, we wanted a solution thatwas fairly easy to implement and produced clinicallymeaningful findings. In the end, we were able to applya single solution to both issues.

Comparing Effects Across Interventions

We first addressed how to interpret results from aregression analysis to make comparisons among inter-ventions that have widely varying use rates. Table 2presents simulated output for an analysis where userates for two different nursing interventions are usedto predict total costs for a hospitalization. The effect foreach nursing intervention is expressed in an unstand-ardized regression coefficient, which means that thevalue of the coefficient (the intervention effect) reflects

the dollar amount by which costs change when thereis a one-unit change in the use rate.

Results in this form are difficult to interpret. First, itdoes not permit direct comparison of the effect of thetypical amount of each intervention on costs. Second,even though the change in cost for a one-unit changein the use rate is approximately the same for bothIntervention X and Intervention Y, a reduction of about$1,500, the interpretation in terms of typical practicediffers substantially between interventions. For Inter-vention X, a one-unit change is nearly one-half of thetotal range and is approximately equal to the changefrom no use of the intervention up to the typical use ofthe intervention. For Intervention Y, on the otherhand, a one-unit change is a change of approximatelyone fifth of the range and is equal to less than onethird of the difference between no use of the inter-vention and the typical use of it. In short, the changein practice associated with a $1,500 reduction in costswould be much more substantial for Intervention Xthan for Intervention Y.

To allow ready comparison of effects among manyinterventions, we chose to express the use rates inrelative rank. With this method of use-rate conversion,one can see immediately that a particular use rate islow or high or typical for that particular interventionand quickly interpret study results. This would beespecially useful in discussing results with nursesactually engaged in doing interventions. If practitionerswere only given intervention use rates that werefound to be effective, without any indication of howthose use rates corresponded to their ordinary practice,the implications would not be so obvious.

Table 1. Examples of Calculation of the Intervention Use Rate for a Hospitalization

Number of times surveillance intervention was used during the hospitalization

Length of the hospitalization (days) Surveillance use rate

Patient A 15 3.0 5.0Patient B 12 4.5 2.7

Table 2. Simulated Regression Output With Dose of Nursing Intervention Represented by Raw Use Rate

Effect p-valueMedian use ratea

Range in use rate

Intervention X –$1,506 < .001 1.1 0.2–2.3Intervention Y –$1,512 < .001 3.5 1.7–6.4

aMedian use rate is provided because the distribution of use rates is skewed.


Slightly different procedures for converting the userates were employed depending upon the proportionof patients that received the intervention. For thosenursing interventions used for between 5% and 95% ofa patient sample, we sorted the cases from lowestto highest use rate for that intervention and thencategorized the cases into four groups. Next, weassigned a distinct code for each group. A code of 0was assigned for those who did not receive the inter-vention. The remaining cases were divided into threeequal groups on the basis of percentile ranking of theuse rate, with a code of 1 assigned to the third with thelowest use rates above zero, 2 assigned to the thirdwith midrange use rates, and 3 assigned to the thirdwith the highest use rates.

When the intervention was used for more than 95%of the sample, a separate category for those who didnot receive the intervention would have produced acategory with a relatively small number of cases, andthat could have resulted in unreliable estimates ofintervention effect. Therefore, for those interventionsused for more than 95% of a patient sample, the caseswere divided into quartiles, and the value 1 was assignedto the quartile with the lowest use rates, including ause rate of 0. Those in the quartile with the nexthighest use rates were assigned the value of 2, and soon for all quartiles.

When an intervention was used for less than 5% ofthe sample, subdividing those who received the inter-vention by use rate level would again have producedcategories with small numbers of cases and resulted inunreliable effect estimates. For those interventionsused for less than 5% of a patient population, a dicho-tomous variable was created coded 1 if the patientreceived the intervention at least once and 0 if not.

The nursing intervention variables were then enteredas categorical explanatory variables in regressionanalyses. Simulated output of an analysis of the effect ofIntervention Z with costs as an outcome is presentedin Table 3 to illustrate how results can be interpretedfor an intervention used for between 5% and 95% of apatient population. Dosage level 0 is the category for

all cases for which the intervention was not deliveredand is used as the reference category. Dosage level1 is the category with the cases that are in the lowestthird of use rates. The effect for each dosage level isexpressed in an unstandardized regression coefficientso that the value is in dollars. These simulated resultssuggest that hospitalizations where a comparativelylow level (Dosage level 1) of the nursing interventionZ was received, have costs $2,554 less than those wherenone of the intervention was received, while thosewhere a typical dose was received, i.e., those in the middledosage level, have costs that are $3,669 less than thosewhere none of the intervention was received.

Including the median use rate for each dosage levelallows other studies to replicate the dosage or com-pare use rates across sites and patient populations.Furthermore, assuming that the amount of effort oneadditional unit of intervention takes is known (anotherarea for future research), actual values make it possibleto say that one can get the same benefit with less effortfrom one type of intervention than from another.

Capturing the Form of Relationships

Representing dose as categories based on percentilesalso provides a solution to the issue concerningrepresentation of the relationship between nursinginterventions and outcomes. Entering the dose of nursing

Table 3. Simulated Regression Output With Dose of Nursing Intervention Represented by Categories of Relative Use (None, Low, Typical, High)

Dosage level

Median use rate for level Effect p-value

Intervention Z 3 9.2 –$3,841 < .0012 5.3 –$3,669 < .0011 2.5 –$2,554 < .0010 Not delivered 0.000 —



intervention into a regression model as a continuousvariable assumes that there is a linear relationshipwith the outcome variable. It is reasonable to havesome question about this due to lack of research in thisarea. Therefore, it is preferable to represent dosage ofnursing intervention in a way that does not impose aparticular shape on the relationship of interventionand outcome. The representation of dose we havedescribed will accommodate a variety of shapes to therelationship of an intervention to an outcome, becauseeach category’s relationship to the outcome is inde-pendent of the relationship of other categories to theoutcome.

Figure 1 shows three different possible shapes forthe relationship between the dose of a nursing inter-vention and an outcome measure. The solid line shows alinear trend, the dotted line shows a trend with aceiling effect, and the dashed line shows a patternwith a high threshold level. For the linear trend, theoutcome measure increases steadily as the dose ofintervention increases. For the trend with a ceilingeffect, the outcome measures increase between the

lowest dose of intervention (category 1) and the nextlowest dose (category 2), but there is no furtherincrease in outcome with further increases in the dose.With the high threshold pattern, there is no effect on theoutcome at all until the intervention dose reaches thehighest level. Only the linear trend will be representedwell by entering the dose of nursing intervention as acontinuous predictor variable in a linear regression.Imposing the linear model on the other two patternswill give a poor fit to the data and result in misleading

p

values. The results will not indicate at what dosage theceiling is reached in the one pattern or the thresholdreached in the other, depriving the researcher andclinicians of critical information about what dose levelis appropriate.

Cautions

The method of representing dose here is intendedto permit a relatively easy way to conduct exploratoryanalysis of the relationship of nursing interventiondosage to outcome where many different nursing inter-ventions are examined at the same time. The authorsbelieve such exploratory analysis is important giventhe very limited amount of information available inthis area. Nevertheless, there are some limitations tothe approach. One is that it may increase the chance oftype I error, that is, concluding an intervention hasan effect when actually it does not. This can happenbecause a larger number of tests will be performedthan if dosage were entered as a single continuousvariable. Therefore, it is best to use this methodwhen the software used will give an overall test forthe effect of the intervention as a whole, in additionto significance tests for different dose levels of theintervention.

On the other hand, the use of this method could alsoresult in type II error, that is, concluding that there isno intervention effect when there actually is one. Thiscould happen because entering dosage as separatecategories provides a less powerful test than enteringdose as a continuous variable, when the relationshipis, in fact, linear.

Figure 1. Examples of Different Possible Shapes of the Relationship Between Dose of Intervention and Outcome


There is an extensive body of literature regarding theanalysis of the shape of the dose–response relationshipsfor pharmaceutical interventions (Chuang-Stein &Agresti, 1997; Simpson & Margolin, 1986; Stewart &Ruberg, 2000). This literature discusses methodsdesigned to protect against type I and II errors. Yet, thesemethods are challenging for an applied researcherto implement and difficult to explain to an audiencewithout advanced statistical training. We think ourapproach is preferable for research aimed at providingusable information to practitioners.

Discussion

It is widely recognized that nurse researchers needto develop an evidence base for nursing practice sothat nurses can make well-grounded decisions aboutwhat nursing interventions they should use and howmuch of each intervention should be provided given aparticular set of circumstances. The ability to measurethe dose of nursing intervention will be essential tothe effort to develop this evidence base. Those whoare conducting effectiveness research should thinkexplicitly about how best to construct measures ofdosage from the available data and how best to reportdosage information so that it can replicated.

This article offers practical methods to deal withcomplicated and difficult issues in representing thedosage of nursing intervention in effectiveness researchusing large datasets. Yet, the methods outlined hereare not definitive solutions for all purposes. Otherresearchers may face different challenges. The choicesresearchers make regarding dosage can have bothdesirable and undesirable consequences, and that factmakes developing the best possible methods to dealwith issues of dosage critical to the advancement ofevidence-based practice.

Acknowledgement.

This research was supported bya grant from NIH (PI: Titler. NINR R01 NR05331).

Author contact: [email protected]

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Measuring the Dose of Nursing Intervention

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