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ntensive and Critical Care Nursing (2012) 28, 208—214

Available online at www.sciencedirect.com

j o ur nal homepage: www.elsev ier .com/ iccn

RIGINAL ARTICLE

sing a didactic model to improve patientbservation skills in neonatal intensive care nurserainees — A pilot study

arianne Trygg Solberga,∗, Bente Silnes Tandbergb, Anners Lerdal c,d

Lovisenberg Deaconal University College, Oslo, NorwayDepartment of Neonatology, Women’s & Children’s Division, Oslo University Hospital-Rikshospitalet, NorwayLovisenberg Deaconal Hospital, Oslo, NorwayDepartment of Gastroenterology, Oslo University Hospital, Norway

Accepted 10 December 2011

KEYWORDSNursing assessment;Congenital heartdefects;Critical care nursing;Clinical competence

SummaryObjectives: To implement a didactic model for students specialising in intensive care nursing(n = 12) and nurses working in neonatal intensive care units (NICU) (n = 17). To evaluate nurseself-assessments following observation of children with congenital heart disease (CHD), beforeand after participation in the programme, as well as the usefulness of the programme.Methodology/design: A pilot study with a pre- and post-test design, using self-administeredquestionnaires.Results: The didactic model increased the number of clinical observations and assessmentsof physiological factors made by both students and NICU nurses during evaluation of childrenwith suspected CHD. The majority of nurses reported that both participation in the programmeand the didactic model were useful and they demonstrated high-level knowledge, accordingto Bloom’s taxonomy for cognitive learning. In particular, subjects found that the literature

provided and structured bedside guidance in the clinical setting assisted learning.Conclusion: Intensive care students and NICU nurses performed clinical observations and phys-ical factor assessments more frequently after completing the programme, compared withbaseline. We speculate that this didactic model may also be useful in other clinical settings.

hts re

© 2011 Elsevier Ltd. All rig

∗ Corresponding author at: Lovisenberg Deaconal University Col-ege, Lovisenberggata 15, 0456 Oslo, Norway. Tel.: +47 22358211;ax: +47 22374934.

E-mail address: marianne.solberg@ldh.no (M.T. Solberg).

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964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved.oi:10.1016/j.iccn.2011.12.005

served.

ntroduction

nowledge and professional competence influence the deci-ions nurses make (Ääri et al., 2008). Thus, they need

o allocate time to learning and reflection. They need aafe practice environment founded on knowledge, so thathey can develop their competence by integrating clinicalxperience, research findings and patient preferences

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Improving nurses observation skills

(Hansen and Severinsson, 2009; Storesund and McMurray,2009).

To assess infants with congenital heart disease (CHD)nurses need to understand the physiology of a wide spectrumof heart defects (Suddaby, 2001). In neonatal intensive careunits (NICUs) accurate information regarding early-stagehaemodynamic changes is necessary to assess the evolutionof a heart problem (Martins Da Silva et al., 2007). In additionto knowledge, nurses need the skills to assess impaired gasexchange, ineffective breathing patterns, activity intoler-ance and decreased cardiac output (Martins Da Silva et al.,2007). A successful patient evaluation requires the nurse tothink about the signs and symptoms (Thompson et al., 2008).A number of clinical and physiological factors are importantduring an evaluation: tachypnea, tachycardia, diaphoresis,vasoconstriction, feeding problems, the child’s oxygen need,as well as auscultation of breath sounds, capillary refill andlaboratory values such as haemoglobin, haematocrit (HCT),platelets and electrolytes (Suddaby, 2001).

Definition of terms and framework

Cognition is a term used to describe how we use knowl-edge when we make assessments and apply those to a task,and can be described as analytical, intuitive or a mixture ofboth (Hammond, 1996). Bloom’s taxonomy of learning objec-tives was developed to allow educators to classify levelsof learning with cognitive dimensions of knowledge, skillsand attitudes (Larkin and Burton, 2008). It is divided intosix levels within the cognitive domain: knowledge of facts,comprehension, application, analysis, synthesis, with eval-uation representing the highest level. At this level studentsdiscuss their assessments (Anderson and Krathwohl, 2001).

Objective of the study

This pilot study investigated whether implementation of adidactic model might improve clinical observations and theassessment of physiological factors amongst students spe-cialising in intensive care nursing and nurses working in aneonatal intensive care unit (NICU) for children with CHD.

The research hypotheses were:

1. After participating in the programme, the intensive carestudents and NICU nurses’ assessment of clinical observa-tions and physiological factors (monitored physiologicalparameters and laboratory reports) will improve.

2. After participating in the programme the intensive carestudents and NICU nurses will judge their own knowl-edge regarding assessment of clinical observations andphysiological factors to have reached a higher cognitivelevel.

Furthermore, we wanted to study whether the studentsand NICU nurses found the programme useful.

Methods

This study was designed as a pilot study to evaluate andcompare the outcome of a didactic model for students and

THda

209

urses with pre- and post-tests (Fig. 1). The model illustrateshe implementation of the intervention and its content, asell as the study design.

The programme consisted of (1) theoretical introductionlectures, suggested reading and self-study); (2) clini-al implementation (clinical supervision, reflection with aupervisor and structured guidance), and was provided tooth students and nurses. The programme emphasised theurses’ knowledge, observations and assessments regardingewborns with CHD. The lectures dealt with pathophysio-ogical processes as a basis for understanding circulationnd haemodynamic consequences in various types of con-enital heart defects. Participants were required to readecommended literature before receiving clinical supervi-ion. Students and NICU nurses reflected together with aupervisor and received structured guidance during clini-al implementation. The supervision provided opportunityo reflect during as well as after actions. This is expectedo improve understanding of a patient’s situation, therebynhancing clinical judgement and the ability to decideppropriate actions (Tanner, 2006). The structured guidanceeviewed participants’ reflections on pathophysiologicalrocesses related to various heart defects, as well as proce-ures for admitting, planning and monitoring, in addition tossessment and management of medical and surgical treat-ent. The respondents answered the post test just a feways after the programme was finished.

he questionnaire

ata were collected for pre- and post test using a 24-tem questionnaire developed for an earlier study whereurses assessed oxygen administration in ventilated pretermatients (Solberg et al., 2011). The participants were askedow often they performed specific observations (from a listf 11 observational items) and assessed specific physiologi-al factors (from 13 items) (see Table 1). The items weref particular relevance to children with CHD (Martins Dailva et al., 2007; Suddaby, 2001). Responses were reportedsing a Likert-type scale ranging from 1 (almost never) to

(almost always). The students and NICU nurses were alsosked to explain how useful they found the experience withhe didactic model, and the extent to which the litera-ure, lectures and structured supervision met their learningeeds (response alternatives were: ‘high’, ‘medium’ andlittle’). After participation in the didactic programme thetudents and NICU nurses were asked to evaluate their ownevel within the cognitive domain; knowledge, applicationr evaluation (see post-test, Fig. 1). In addition, we col-ected data on the participants’ educational backgroundi.e. nurse, NICU nurse, other nursing specialisation, rele-ant in-hospital training course) and clinical experience (i.e.ears of experience as a nurse, with CHD, and as a NICUrained nurse).

articipants and setting

he study took place in the NICU of the Oslo Universityospital-Rikshospitalet. Information about the project wasistributed to clinical heads of departments, nurse man-gers, the participants and other contact persons. Consent

210 M.T. Solberg et al.

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Figure 1

as assumed when participants answered the questions andeturned the forms (Polit and Beck, 2008). Nineteen partic-pants were nurses enrolled in the NICU specialist trainingrogramme. In addition, 21 of the approximately 100 nursesmployed in the NICU were invited to participate in thetudy. The inclusion criterion for NICU nurses was managerialssessment of their need for guidance. Total response ratet follow-up was 72.5%, n = 29. Data were collected betweenpril 2009 and May 2010.

Both specialist students (median = 5.0,ange = 2—11 years) and NICU nurses (median = 5.5,ange = 0.5—30 years) were relatively experienced. Ofhe NICU nurses 8 were intensive care specialists. Thenit has approximately 850 hospitalisations annually. Theverage length of stay was 12 days. The hospital is thenly one in Norway which offers surgical treatment to

hildren with CHD. The NICU receives approximately 250HD admissions per year.

Table 1 Variables used in the questionnaire.

Clinicalobservations

Physiological factors

Skin colour Oxygen saturationCyanosis Pre- and post-ductal

oxygen saturationCapillary refill pO2

Peripheralcirculation

pH

Fluid balance pCO2

Urineproduction

Hb—O2 curve

Oedema TemperatureAuscultation of

the lungsPulse

Tachypnea Blood pressureWeight HaemoglobinGastrointestinal

symptomsHaematocrit

PlateletsElectrolytes

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y overview.

tatistics

tatistical analyses were conducted using SPSS version 18.0SPSS Inc., Chicago, IL, USA). Descriptive statistics and fre-uencies were calculated. Non-parametric statistics weresed to test the difference between two independentroups, based on ranked scores, i.e. the Mann—Whitney Uest. This test was used to analyse the difference betweenwo groups, where the dependent variable was measuredn an ordinal scale for a small sample size, so normal dis-ribution cannot be assumed (Polit and Beck, 2008). Theest involved assigning ranks to two groups of measures. Theann—Whitney U test was used to test whether there was a

tatistically significant difference in use of the physiologicalnd clinical factors by students (group 1) and NICU nursesgroup 2). All tests were two-tailed, a p-value of <0.05as considered significant. Effect sizes (Cohen’s coefficient) were calculated to compare the baseline and follow-upffects, for the students and the nurses. A d value ≥0.4 wasonsidered a meaningful effect size (Cohen, 1992). Cohen’soefficient d is a standardised measure for effect size, andepresents the difference between the means divided by theooled standard deviation (SD).

thics

thics approval was not required for this study because inorway the regional committees for medical research do noteview studies of health care workers as long as data on theirealth issues are not included. The study did not collect anyensitive data.

esults

ssessment of clinical observations at baseline andollow-up

t baseline, NICU nurses used all the clinical observationsore frequently than the students (Table 2). Differences

etween the NICU nurses and the students were signif-cant for: urine production (Z = —2.69, p = 0.02), oedemaZ = —2.47, p = 0.03), weight (Z = —2.58, p = 0.01) and gas-rointestinal symptoms (Z = 2.51, p = 0.02). The follow-up

Improving nurses observation skills

Tabl

e

2

Clin

ical

obse

rvat

ions

used

in

asse

ssm

ents

of

CHD

at

base

line

and

follo

w

up.

Vari

able

s

Base

line

Follo

w-u

p

Stud

ents

n

=

17N

ICU

nurs

es

n

=

18

Stud

ents

n

=

12

NIC

U

nurs

es

n

=

17

Clin

ical

obse

rvat

ions

Med

ian

Mea

n

SD

Med

ian

Mea

n

SD

Med

ian

Mea

n

SD

d

Med

ian

Mea

n

SD

d

Skin

colo

ur

5.0

4.8

0.4

5.0

4.8

0.4

5.0

4.8

0.6

0

5.0

4.9

0.2

0.3

Cyan

osis

5.0

4.8

0.4

5.0

4.7

0.6

5.0

4.8

0.6

0

5.0

4.9

0.2

0.4

Capi

llary

refil

l

4.0

3.7

1.2

5.0

3.9

1.5

4.0

4.0

0.9

0.3

5.0

4.6

0.6

0.6

Peri

pher

al

circ

ulat

ion

4.0

4.3

0.7

5.0

4.6

0.7

5.0

4.7

0.5

0.7

5.0

4.9

0.3

0.6

Flui

d

bala

nce

4.0

4.3

0.7

5.0#

4.6

0.8

4.5*

4.4

0.7

0.1

5.0*,

#5.

0

0.0

0.7

Uri

ne

prod

ucti

on4.

0*,#

4.2

0.7

5.0*

4.7

0.5

5.0#

4.7

0.5

0.8

5.0

4.9

0.2

0.5

Oed

ema

4.0*

4.2

0.6

5.0*

4.7

0.5

4.0*

4.0

0.9

0.3

5.0*

4.8

0.4

0.2

Ausc

ulta

tion

of

the

lung

s

4.0

3.7

0.9

4.0

3.7

1.2

4.0

4.0

0.7

0.4

4.0

4.2

0.8

0.5

Tach

ypno

ea

5.0

4.4

0.8

5.0#

4.4

0.8

4.5

4.4

0.7

0 5.

0#4.

9

0.3

0.8

Wei

ght

4.0*

3.6

1.0

5.0*

4.4

0.8

4.0*

4.1

0.8

0.6

5.0*

4.8

0.4

0.6

Gas

troi

ntes

tina

l sym

ptom

s

3.0*

3.3

1.1

4.5*,

#4.

3

0.8

4.0*

4.1

0.8

0.8

5.0*,

#4.

8

0.4

0.8

Resp

onse

s

to

the

11

item

s

wer

e

repo

rted

usin

g

a

Like

rt-t

ype

scal

e

rang

ing

from

1

(alm

ost

neve

r)

to

5

(alm

ost

alw

ays)

.d

repr

esen

ts

the

effe

ct

size

of

the

diff

eren

ces

betw

een

base

line

and

follo

w-u

p

mea

n

scor

es,

as

Cohe

n’s

d.*

Sign

ifica

nt

diff

eren

ces

(p

<

0.05

)

betw

een

stud

ents

and

NIC

U

nurs

es

(Man

n—W

hitn

ey

U

test

).#

Sign

ifica

nt

diff

eren

ces

(p

<

0.05

)

wit

hin

grou

ps,

betw

een

base

line

and

follo

w

up.

smfoa

taotsorc

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Ttcn

ssb

tctn(utio

aHstNuH

L

Prac

al

P

TtA

211

howed that NICU nurses still used all clinical observationsore frequently than the students, with significant dif-

erences in relation to: fluid balance (Z = —3.21, p = 0.02),edema (Z = —2.87, p = 0.01), weight (Z = —2.53, p = 0.03)nd gastrointestinal symptoms (Z = —2.81, p = 0.01).

We compared participant use of observations and foundhat the mean values for students were significantly highert follow-up (i.e. learning outcomes) for the observationf urine production, fluid balance, tachypnea and gas-rointestinal symptoms. However, the effect sizes wereignificantly higher at follow-up for most of the studentbservations, except for skin colour, cyanosis, capillaryefill, fluid balance, oedema and tachypnea and for skinolour for the NICU nurses (Table 2).

ssessment of physiological factors at baseline andollow-up

he assessment of all physiological factors showed aendency towards more frequent reporting at follow-up,ompared with the baseline, for both students and NICUurses.

However, only the increased assessment of the pulse wastatistically significantly (Z = —2.13, p = 0.03). Table 3 showstudent and nurse assessments of physiological factors ataseline and follow-up.

Analysis of baseline data showed that students had aendency to assess patient pO2, pH, pCO2 and the Hb—O2

urve more frequently than NICU nurses. However, theserends were not statistically significant (Table 3), and, NICUurses used pre- and post-ductal saturation more oftenZ = —2.38, p = 0.03). NICU nurses reported more frequentse of physiological factors than students at follow-up, withhe exception of PO2 and the Hb—O2 curve. The only signif-cant difference between the groups was in the assessmentf platelets (Z = —2.84, p = 0.01).

The mean scores for physiological factors did not indicateny differences between groups at baseline and follow-up.owever, analysis of effect sizes showed that students wereignificantly more likely to use pre- and post-ductal SaO2,he Hb—O2 curve, temperature, pulse, Hct and platelets.urses were significantly more likely to use pO2 and pH val-es from blood gases, the Hb—O2 curve, temperature andct in the follow-up (Table 3).

evel of cognitive learning

articipants reported changes in their level of knowledge inelation to cognitive learning outcome. Students reported

higher level of learning related to clinical observations,ompared with NICU nurses (Fig. 2).

The groups reported relatively similar learning outcomess regards the level of knowledge used in assessing physio-ogical factors (Fig. 3).

articipant opinion of the didactic model

wenty-six of the 27 respondents (96%) reported thathe didactic model was of great or medium usefulness.ll respondents reported that theoretical introduction,

212

M.T.

Solberg et

al.

Table 3 Physiological factors used in assessments of CHD baseline and follow-up.

Variables Baseline Follow-up

Students n = 18 NICU nurses n = 16 Students n = 11 NICU nurses n = 14

Physiological factors Median Mean SD Median Mean SD Median Mean SD d Median Mean SD d

Oxygen saturation 5.0 4.7 0.8 5.0 4.9 0.3 5.0 4.8 0.4 0.2 5.0 5.0 0.0 0.5Pre- and post-ductal SaO2 4.0* 3.4 1.4 5.0* 4.5 0.7 4.0 4.2 0.8 0.7 5.0 4.6 0.5 0.2pO2 4.0 4.3 0.8 3.5 3.6 1.1 5.0 4.4 0.8 0.1 5.0 4.2 1.2 0.5pH 5.0 4.4 0.8 4.0 3.9 0.9 5.0 4.5 0.7 0.1 5.0 4.4 1.0 0.5pCO2 5.0 4.5 0.6 4.0 4.0 1.0 5.0 4.3 0.9 0.3 5.0 4.6 0.8 0.7Hb—O2 curve 3.0 2.9 1.0 2.0 2.3 1.3 4.0 3.3 1.2 0.4 3.0 3.2 1.4 0.7Temperature 4.0 3.9 1.0 4.0 4.0 1.1 5.0 4.5 0.7 0.7 5.0 4.6 0.5 0.7Pulse 5.0 4.6 0.5 5.0 4.8 0.4 5.0 4.8 0.4 0.4 5.0 4.9 0.3 0.3BT 5.0 4.5 0.6 5.0 4.8 0.6 5.0 4.6 0.7 0.2 5.0 4.9 0.4 0.2Hb 4.0 4.2 0.7 4.5 4.2 0.9 4.0 4.2 0.8 0 4.5 4.4 0.6 0.3Hct 2.5 2.7 1.1 3.0 3.2 1.0 3.0 3.3 0.5 0.7 3.0 3.6 0.9 0.4Platelets 3.0 2.9 1.1 4.0 3.8 1.0 3.0* 3.3 0.6 0.6 4.0* 4.0 0.7 0.2Electrolytes 4.0 3.9 0.8 4.5 4.3 0.8 4.0 3.9 1.0 0 4.0 4.4 0.6 0.1

Responses to the 13 items were reported using a Likert-type scale ranging from 1 (almost never) to 5 (almost always).d represents the effect size of the differences between base-line and follow-up mean scores, as Cohen’s d.

* Significant differences (p < 0.05) between students and NICU nurses (Mann—Whitney U test).

Improving nurses observation skills

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ttas

D

OsbibtsotrftKartobdeiiaPpp

Figure 2 Changes in knowledge level when making clinicalobservations following the didactic programme.

reflection with a supervisor, and structured supervision, mettheir knowledge needs. Furthermore, 18 of 26 respondentsreported that the lectures met their needs.

Limitations

The groups used in this pilot study were small. Several of thenon-significant statistical differences between groups, andtimes of measurements, showed relatively high effect sizes.The lack of significant statistical differences may be becauseof Type II errors and the small sample size. If the study hadmore participants and these participants had shown simi-lar learning outcomes, the analyses would have identifiedstatistically significant changes in more of the variables.Therefore, the study needs to be replicated with a largersample size.

Another weakness is related to the multipleMann—Whitney U tests performed in this study. Themultiple tests increase the risk for Type I error, i.e. reject-ing a true null hypothesis. Bootstrapping would have beenour preferred statistical method. This method was not useddue to lack of access this statistical test. Thus, the studyfindings should be interpreted with caution until the studyhas been replicated in a larger sample. Furthermore, theresults maybe due to the Hawthorne effect, witch meansthat the results shown at follow-up may be an effect of

being involved in a study per se (Polit and Beck, 2008).

This programme was a pilot study aimed at students intraining and NICU nurses who needed to improve clinicalobservation skills, and auscultation of heart sounds was not a

Figure 3 Changes in knowledge level when assessing physio-logical factors following the didactic programme.

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213

kill required at that time. Auscultation of heart sounds as akill should be implemented in a larger study. The pilot studyas based on self-reporting by students and NICU nurses,nd elicited their opinion of assessments. The effect of theodel was not measured against a control group. In addi-

ion, students or NICU nurses reflected with a supervisornd teacher; they may be less attentive if they had no suchelationship with a supervisor.

From a longitudinal perspective, it is uncertain whetherhe findings of the study imply that nurses will use more cri-eria during their assessments of children. As this was a pilot,

full study would be needed before wider applicability isuggested.

iscussion

ur study showed that the didactic programme increasedtudent and NICU nurse clinical observations of fluidalance, tachypnea and gastrointestinal symptoms. Datandicated significant improvements in the observations byoth groups as regards peripheral circulation, urine produc-ion, auscultation of the lungs and weight. Both groups alsohowed significant improvements in the assessment of physi-logical factors, including measurement of temperature andhe Hb—O2 curve of newborns. The majority of participantseported that they found the didactic model to be use-ul and they also reported high-level knowledge, accordingo Bloom’s taxonomy for cognitive learning (Anderson andrathwohl, 2001). Reflection in action provided nurses with

better ability to determine a child’s CHD status. Furthereflection upon the child responses to a nursing interven-ion gave them opportunities to adjust interventions basedn their assessments. Reflection on actions also providedoth students and nurses with ongoing clinical knowledgeevelopment, which could enhance their future clinicalvaluations. As a consequence, they had a more analyt-cal approach to observation and assessment, which maymprove quality of care. This study found that students had

tendency to assess physiological factors such as pO2, pH,CO2 and Hb—O2 curve more frequently than NICU nurses. Aossible explanation may be that this topic has been givenarticular attention in lectures at the university college asart of the general curriculum. Thus, students may haveeen well trained in the importance of understanding these of these factors in their nursing assessments. Hammond1996) has noted that the only way to achieve good taskssessments is through education. In addition, critical think-ng depends on domain knowledge and practice (Willingham,007).

It is claimed that it is important to develop both basic,ontinuing education and internship programmes for inten-ive care nurses (Ääri et al., 2008). Our didactic modelatisfied these conditions by providing: a theoretical intro-uction with lectures, literature for self-study, clinicalmplementation and bedside reflection together with a clin-cal supervisor and structured supervision for the NICUomain.

In the follow-up most respondents reported that theirnowledge needs had been satisfactorily met, especially inelation to provision of literature, reflection with a super-isor and structured supervision. Reflection has been shown

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o be a process where knowledge is moved from the sub-onscious to the conscious Such a process is essential indvanced decision-making which has to take into accounthe individual as well as holistic needs of the patient. Theheoretical introduction provided both groups with in-depthedical knowledge about the physiological impact of CHD.

urthermore, they also read about nutrition, feeding dif-culties and parent education. Thus, students and nursessed self-study to reach a level of knowledge appropriateor reflection with the supervisor during the clinical imple-entation of the programme.The significant improvement in the assessment of the

b—O2 curve was important, because children with CHDave increased pulmonary blood flow and oxygen can actu-lly worsen their symptoms (Suddaby, 2001). In contrast,xygen is not required even if the child has low blood flow,ecause it will not produce any effect (Suddaby, 2001). Indi-ators, including, paO2, paCO2, pH, systolic blood pressure,ulse pressure and O2 saturation have recently been vali-ated to define ineffective breathing patterns in childrenith CHD. These indicators can improve nurses’ diagnostic

kills and effective communication, by better understand-ng the phenomena encountered during the assessment ofhildren with CHD (Martins Da Silva et al., 2010). The super-isor provided participants with insight into observationshat were clinically relevant to the evaluation of newbornsith CHD. By participating in reflection with a supervisor,

tudents and nurses were able to connect theory and prac-ice.

onclusion

his pilot study indicated that intensive care students andICU nurses performed more clinical observations and phys-

cal factor assessments after completing the programmeompared with baseline. Students reported higher cog-itive learning outcome levels. The tight integration ofheory and practice in the didactic model implementedn this study allowed students and staff to meet learn-ng outcomes, which addressed their knowledge needs andnabled them to draw on many observations in their assess-ents. This model may be applicable to health care workers

nvolved with other patient groups in different clinicalettings.

unding source

his project was supported by Lovisenberg Deaconal Univer-ity College, Oslo, Norway.

W

M.T. Solberg et al.

onflict of interest statement

he authors have no conflict of interest.

cknowledgment

e thank Professor Thor Willy Ruud Hansen, MD, PhD, for hisontributions to the linguistic revision of this manuscript.

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