Comorbid Alcohol Disorder Intensifies Patterns of Psychological Symptoms Among Women

ORIGINAL RESEARCH

Comorbid Alcohol Disorder Intensifies Patterns of Psychological Symptoms Among Women Pamela Newland, RN, PhD, Sarah Meshberg-Cohen, PhD, Louise Flick, DrPH, MSN, Kate Beatty, PhD, MPH, and Judith M. Smith, PhD, RN ABSTRACT

This secondary analysis describes the additional psychological symptoms experienced by women in substance abuse treatment who have an alcohol use disorder (AUD) in addition to a drug use disorder (DUD). Results show high levels of certain patterns of psychological symptoms, which include Paranoid Ideation, Phobic Anxiety, Anxiety, and Psychoticism, on the Brief Symptom Inventory (BSI) subscales. Also, age had an adverse effect, with Depression and Psychoticism scores higher with increasing age. Nurse practitioners are ideally situated to assess and screen for patterns of co-occurring psychological symptoms in women with an AUD, which can complicate treatment and lead to practice implications. Keywords: alcohol use disorders, psychological symptoms, women Ó 2015 Elsevier, Inc. All rights reserved.

BACKGROUND

D

espite awareness of the prevalence and harmful effects, drug and alcohol use is increasingly prevalent among women. Women with drug use disorders (DUDs) report overwhelming rates of other mental health problems,1,2 including posttraumatic stress disorder (PTSD), paranoid conditions,3,4 and depression.5-8 The use of drugs and alcohol may be a form of self-medication, while substance use can also induce psychiatric symptoms and exacerbate social difficulties.9 Alcohol is a legal substance and more widely accepted than illicit drugs, yet excessive drinking over time can lead to health problems, including various cancers, unintentional injuries, violence, birth defects, and social difficulties.11 National surveys indicate that 55% of women aged 15-44 years report current alcohol use.10,11 Problematic drinking among women can have detrimental short- and long-term social and health-related consequences, including brain12 and liver damage.13,14 The increasing prevalence of DUDs among women4,15 and the associated adverse health consequences are of great public health importance.12 618

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There is extensive literature on the relationship between DUDs, depression, anxiety, and suicide, yet less attention has been devoted to exploring the patterns of physical symptoms (eg, pain) and psychological symptoms (eg, distress) that may occur in the subgroup of women seeking substance use disorder (SUD) treatment who present with both a DUD and an alcohol use disorder (AUD).15 Despite strong epidemiologic studies of the general population indicating that problematic drinking is associated with anxiety and depressive symptoms and co-occurring psychiatric disorders, few studies have estimated the additional symptom burden among DUD treatment‒seeking women who have alcohol as one of their primary substances of use. Also, few studies have addressed the co-occurrence of certain patterns of symptoms among those with AUD (versus those without AUD). Multiple patterns of psychological symptoms (eg, anxiety, depression) and distress may compound each other, such that women with both DUD and AUD suffer from much greater impairment relative to women with DUD without problematic alcohol use.16 The presence of persistent patterns of psychological distress seen among women with AUDs (eg, paranoid ideation, anxiety) can Volume 11, Issue 6, June 2015

exacerbate the alcohol use.17 Bobo and Greek18 noted that depression and alcohol use co-occur over time,18 and that increased depression leads to greater alcohol use.15,19 Nurse practitioners (NPs) in the primary care settings do not routinely assess for AUDs among women with DUDs or other associated psychiatric disorders and patterns of symptoms, including somatic symptoms (eg, pain, nausea).17 The purpose of this study is to examine the psychological symptoms among women with DUDs who present to residential SUD treatment with and without AUDs. It is hypothesized that women with DUDs and AUDs who present for residential treatment will report different psychological symptoms when compared to those with DUDs but without AUDs. Findings from this study will provide insight into cooccurring psychological symptoms that may be found among women in residential substance treatment who have the additional burden of an AUD. METHODS AND STUDY DESIGN

This cross-sectional, descriptive study is a secondary analysis of data from a randomized clinical trial of women in residential SUD treatment. SUD is defined here as including an AUD or DUD. Results from this intervention study have been reported elsewhere.20 The university’s human subjects institutional review board approved the original study. Participants included 149 women admitted to a gender-specific residential SUD treatment facility from June 17, 2007 to November 6, 2008. Specific services within this facility include individual counseling, motivational enhancement therapy groups, and case management for such needs as housing, transportation, and child care. To be eligible for the study, women had to: (a) be
18 years old; (b) meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria for a SUD; and (c) have approval for 60 days of residential treatment from a third-party payer. Women were ineligible if they: (a) had an acute mental disorder (eg, current suicidality) that would make it difficult to provide informed consent or follow the study protocol; or (b) had literacy problems that would prevent them from being able to complete the intervention. To allow testing www.npjournal.org

the added burden of having both an AUD and a DUD compared to those with only a DUD, we excluded 9 women diagnosed with an AUD who had no comorbid DUD, making our total sample 140 women. Sample and Procedure

Participants in the study completed assessments administered in person at baseline and at a 2-week and 1-month postintervention follow-up. For this study, analyses relied on baseline data only. Participants received a $5 gift card for baseline assessments. Measures

The Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition21 is a semistructured diagnostic interview for DSM-IV-TR Axis I disorders. Our study focused only on the Alcohol and Drug Use modules, which have demonstrated high interrater reliability and good validity for DSM-IV-TR diagnoses of these disorders.9 In keeping with the new DSM-5,24 rather than using abuse and dependence as separate disorders (all participants in this study met dependence criteria according to the DSM-IV-TR for substance[s] of use), we investigated abuse/dependence as a single disorder for both DUD and AUD. The Posttraumatic Stress Diagnostic Scale (PDS)17 is a 49-item self-report measure focused on PTSD symptom severity and diagnosis, with items parallel to DSM-IV-TR criteria.9 The PDS score has high testretest reliability (r ¼ 0.83), high internal consistency (a ¼ 0.92), and high convergent validity. Trauma symptom severity was defined as the summed scores for items focused on re-experiencing, arousal, and avoidance symptoms. At baseline, internal consistency for trauma symptom severity for this sample was a ¼ 0.99. The Brief Symptom Inventory (BSI),22 a 53-item self-report measure, is a shortened version of the Symptom Check List-90. It assesses 9 patterns of psychological symptoms of distress (Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism). The total BSI score provides a summary measure of overall symptom burden or distress. The BSI has high scale-by-scale The Journal for Nurse Practitioners - JNP

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correlations with the Symptom Check List-90, as well as high internal consistency (Cronbach’s a ¼ 0.71-0.85); convergent, discriminant, and test-retest reliability (r ¼ 0.68-0.91); and construct validity.23 Internal consistencies for the 9 BSI indices for this sample were a ¼ 0.74-0.87. Demographic questionnaire. At baseline, participants completed a demographic questionnaire that included questions about age, race/ethnicity, marital status, occupational status, religion, and educational history. DATA ANALYSIS

Statistical analyses were performed using SPSS version 21.0. Descriptive statistics illustrate the distribution of each characteristic. For continuous variables means and standard deviations were reported, with frequencies and percentages reported for categorical variables. To compare demographic variables, chi-square and independent samples t-tests were computed. Finally, multivariable linear regression models were computed with each BSI psychological distress scale (Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism) as the dependent variable, to test the main effect of an AUD on each symptom scale adjusting for age, race, and ethnicity. A logistic regression model was also run with the dichotomous PTSD diagnosis (yes/no) as the dependent variable to adjust for confounding. For all women with a DUD, we tested the significance of adding AUD to the model, as compared with a model including demographic variables alone (age, race, and ethnicity). The b values and their 95% confidence intervals (CIs) were reported, along with the significance level of the change in F test and the overall R2 for each model for the multiple regression models. For PTSD the odds ratio and 95% confidence intervals were reported. RESULTS Study Population

The study population consisted of 149 women with a DUD who were admitted to a gender-specific residential SUD treatment facility. As shown in Table 1, over two thirds of the women were African American, with an average age of 36.2 years, ranging in age from 620

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19 to 49, and > 50% of the women met criteria for current PTSD. There were no statistically significant differences in race/ethnicity, PTSD diagnosis, or age, based on AUD. Drug-using women with AUDs had significantly higher total BSI scores compared to those without AUDs (P < .05). In addition to having significantly higher overall BSI scores, women with AUDs had statistically significantly higher combined subscale scores for Paranoid Ideation, Psychoticism, Phobic Anxiety, and Anxiety, when compared to women without AUDs (Table 2). Bivariate analysis revealed race and ethnicity were not predictors of BSI total score or any BSI subscale. Age was the only significant demographic variable, as it related significantly to both Psychoticism and Depression scores. For every 1-year increase in age, women’s Psychoticism and Depression scores increased by 0.1 (P < .05) (Table 2). AUD was associated significantly with higher BSI scores, indicating more symptoms, in 4 of the models: BSI total score, Psychoticism, Anxiety, and Paranoid Ideation. The adjusted R2 shows that the models accounted for 8%-24% of the variance in BSI scores. Binary logistic regression analysis for PTSD (yes/no), adjusting for confounders of age, race, or ethnicity, showed no significant relationships, and the model as a whole was not significant. DISCUSSION

In this study we have found that an AUD in addition to a DUD was associated with more severe clinical profiles among women in residential SUD treatment. This finding is particularly noteworthy considering that women with DUDs, as a whole, are likely to report higher levels of distress and comorbid psychiatric problems, compared to women without DUDs.4 More specifically, our results indicate that women who present with both a DUD and an AUD reported higher levels of symptoms in 4 psychological domains on the BSI compared with those who did not meet criteria for AUD, including Paranoid Ideation, Phobic Anxiety, Anxiety, and Psychoticism. Table 1 shows that women in our sample reported a prevalence of PTSD of 55% (77/140), which is much higher than the general population rate for women of 5.2% for past year and 9.7% for lifetime prevalence (National Volume 11, Issue 6, June 2015

Table 1. Demographics and Psychological Characteristics of Study Population by Alcohol Use Disorder in Women (N [ 149) Alcohol Alcohol Total Disorder: Disorder: Sample Yes (n ¼ 34) No (n ¼ 106) (N ¼ 140) Age [mean (SD)], 36.6 (9.3), range (in years) 19-54

35.6 (8.0), 19-59

35.9 (8.3), 19-59

11.4 (1.9)

11.1 (1.7)

11.2 (1.8)

Last grade completed [mean (SD)]

Married

3 (27.2)

8 (72.7)

11 (100)

Divorced

8 (25.0)

24 (75.0)

32 (100)

Widowed

2 (33.3)

4 (66.7)

6 (100)

21 (23.1)

70 (76.9)

91 (100)

Unemployed

25 (22.1)

88 (77.9)

113 (100)

Homemaker

0 (0.0)

2 (100.0)

2 (100)

Disability

2 (100.00)

0 (0.0)

2 (100)

Full-time

4 (30.8)

9 (69.2)

13 (100)

Part-time

3 (30.0)

7 (70.0)

10 (100)

African American

22 (22.0)

78 (78.0)

100 (100)

White

11 (34.4)

21 (65.6)

32 (100)

Employment status [n (%)]

Race/ethnicity [n (%)]

Hispanic

0 (0.0)

1 (100.0)

1 (100)

Other

1 (14.3)

6 (85.7)

7 (100)

22 (28.6)

55 (71.4)

77 (100)

PTSD diagnosis [n (%)] Yes No

12 (19.0)

51 (81.0)

63 (100)

75.7 (45.7)

53.8 (36.6)

59.2 (39.9)

BSI Psychoticismb 12.1 (8.5)

7.7 (6.6)

8.7 (7.3)

BSI Somatization

8.3 (7.3)

6.2 (5.1)

6.7 (5.8)

10.8 (7.0)

8.3 (7.0)

8.9 (7.0)

BSI Hostility

5.1 (4.8)

3.5 (3.4)

3.9 (3.9)

BSI Phobic Anxietya

6.7 (5.6)

4.2 (4.3)

4.8 (4.7)

Total BSI scorea [mean (SD)]

BSI Depression

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Total Alcohol Alcohol Sample Disorder: Disorder: Yes (n ¼ 34) No (n ¼ 106) (N ¼ 140) BSI ObsessiveCompulsivea

11.4 (6.7)

7.6 (5.2)

9.3 (6.4)

BSI Anxietyb

8.4 (6.4)

5.4 (5.3)

6.2 (5.7)

BSI Paranoid Ideationa

9.2 (5.6)

6.9 (5.0)

7.5 (5.2)

BSI ¼ Brief Symptom Inventory; PTSD ¼ posttraumatic stress disorder. a P < .05. b P < .01.

Marital status [n (%)]

Single

Table 1. (continued)

Co-Morbidity Survey, 2005). However, those with both a DUD and an AUD did not have a significantly higher prevalence of PTSD than those with only a DUD. Women with both a DUD and an AUD reported more symptoms of paranoid ideation, phobic anxiety, anxiety, and psychoticism than DUD women without alcohol problems. Chronic, excessive alcohol use can place women at risk for developing feelings of anxiety, which could lead to a vicious cycle of use and withdrawal.15,19 If left untreated, withdrawal symptoms can lead to paranoia, psychosis, and ultimately death.15 Thus, women with both a DUD and an AUD who present for treatment may have different needs for therapeutic support and symptom management compared with their nonalcohol-using counterparts. Clearly, there is an added need for strategies for prevention and treatment of psychological problems in those women with a DUD plus an AUD. An interesting finding is that, as age increased, so did reported levels of psychological symptoms for psychoticism and depression. Consistent with previous literature,18,27 our analysis has shown that, as women age by 1 year, they experience higher levels of certain patterns of symptoms than their younger counterparts. However, replication and larger cohort studies are still needed to determine whether this is a true age effect, a cohort effect, or simply a function of duration of heavy alcohol consumption. As women age, the effects of excessive drinking can impair the functioning of various organs in the body, including the brain, heart, liver, pancreas, and immune system, which could lead to disruptions in mood and The Journal for Nurse Practitioners - JNP

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Table 2. Psychological Symptoms in Women with Drug Use Disorders by Alcohol Use Disorder (N[149). NS Model Model 1: BSI Total Covariates Constant

NS Model

Model 2: BSI Psychoticism

B (95% CI) 0.5 (1.3, 0.2)

Model 3: BSI Somatization

Model 4: BSI Depression

NS Model Model 7: BSI ObsessiveCompulsive

Model 6: BSI Phobic Anxiety

Model 5: BSI Hostility

Estimates

Model 9: BSI Paranoid Ideation

Model 8: BSI Anxiety

B estimates

B estimates

B estimates

B estimates

Estimates

2.5 (3.0, 8.0)

3.4 (1.0, 7.8)

5.1 (0.3, 0.5)

5.0 (2.0, 7.9)c

4.8 (1.2, 8.4)b

4.7 (0.2, 9.5)

Estimates

Estimates

0.3 (0.5, 1.1)

0.5 (0.5, 1.5)

0.3 (1.1, 1.6) 0.2 (1.4, 1.0)

5.1 (0.8, 9.4)a

3.2 (0.7, 7.2)

Race (ref ¼ black / AA) White Other

0.0 (0.2, 0.2) 0.2 (1.7, 1.3)

0.0 (1.3, 1.2) 0.5 (1.9, 1.0)

0.7 (0.4, 1.7)

0.6 (1.3, 0.2) 2.2 (7.8, 3.3) 3.3 (7.8, 1.1) 3.8 (9.3, 1.7) 2.6 (5.6, 0.4) 2.4 (6.1, 1.3) 1.4 (6.3, 3.6) 3.3 (7.7, 1.1) 1.5 (5.5, 2.5)

Age (continuous)

0.0 (0.0, 0.0)

Alcohol use (ref ¼ no)

0.5 (0.1, 0.9)

R2 Adjusted R2

0.2 (0.0, 0.3)a

0.1 (0.0, 0.2)

0.1 (0.0, 0.3) 0.1 (0.1, 0.0) 0.0 (0.1, 0.1)

0.1 (0.0, 0.2)

0.0 (0.1, 0.1)

0.1 (0.0, 0.2)

2.8 (0.3, 5.2)

2.8 (0.6, 5.0)

2.3 (0.3, 4.3)a

4.1 (1.3, 6.9)

1.9 (0.3, 4.1)

2.1 (0.6, 4.9)

1.7 (0.2, 3.2)

2.5 (0.7, 4.4)

0.09

0.10

0.06

0.06

0.07

0.08

0.07

0.07

0.09

0.06

0.08

0.04

0.03

0.05

0.05

0.04

0.04

0.06

b

b

a

Bold values are statistically significant.

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Constant indicated as z-scores. AA ¼ African American; BSI ¼ Brief Symptom Inventory; CI ¼ confidence interval; NS ¼ nonsignificant. a P < .05. b P < .01. c P < .001.

b

a

a

behavior, as well as problems with thinking clearly and attending to detail.27 NPs in primary care settings may not routinely identify, evaluate, or treat women with psychological problems who present to primary care clinics. In light of the patterns of psychological symptoms in women with an AUD in this study, it is important that NPs screen for alcohol use, as women may be unlikely to voluntarily report disordered drinking. Routine screening practices for, and standardized approaches to, assessment, referral, and treatment, especially pharmacologic intervention, are available to providers utilizing the Substance Abuse and Mental Health Services Administration’s standardized approach based on screening, brief intervention, and referral to treatment,27 which is an evidence-based practice that incorporates a motivational interviewing style. This resource can identify and reduce problematic alcohol and substance use. Women who use alcohol may feel anxious about the amount of their intake and minimize their intake or deny alcohol abuse altogether. To accurately assess the level of alcohol use, NPs should first establish a trusting relationship with these women.19 Furthermore, women seeking treatment for a DUD may be even more likely to minimize their alcohol consumption, due to feeling it is a lesser problem for them compared with illicit drug use. NPs should display empathy and understanding while maintaining a nonjudgmental attitude whereupon a foundation of open communication can be initiated. Prescription or illicit drug use may distract from an underlying AUD.28 The presence of AUD among women seeking DUD treatment adds to the burden of psychological symptoms above and beyond those experienced by women with a DUD without an AUD. Furthermore, NPs should inquire about past alcohol use as well as patterns and frequencies of current use. Psychiatric NPs should assess psychiatric history as well, inquiring about any comorbid problems, such as depression, bipolar disorder, personality disorder, or PTSD. Because the BSI focuses on psychological symptoms, it allows us to compare the level of distress among women in SUD treatment with a DUD and AUD with those without an AUD. Consistent with previous research,13,25 AUDs were related to depression, www.npjournal.org

loneliness, psychosis, and other psychiatric disorders. Our findings add to previous research15,16,26 by revealing that women with alcohol use diagnoses in addition to a DUD are more compromised emotionally than women with a DUD without alcohol problems. Although our findings contribute to the current understanding of women in residential SUD treatment who report both DUDs and AUDs, several limitations of our research should be noted. First, the use of the Structured Clinical Interview for DSM-IV-TR did not allow identification of subtypes of psychiatric symptoms and risky behavior (eg, suicide ideation, amount of alcohol use). The small sample size and recruitment from a single treatment facility also limit generalizability. Larger studies examining our findings are needed. Although the BSI has sound psychometric properties, it may not be the most appropriate screening tool for symptoms in women who have AUDs. Similar to other studies,29,32 recall bias is likely present with self-reported alcohol or drug use. Last, the all-female sample precludes generalizing these results to men. However, women with DUDs represent an underserved population and our gender-specific sample can also be viewed as a strength of the current study. Previous studies have focused on the risk of associated psychiatric disorders among those with AUDs, but rarely is there the opportunity to compare the psychiatric symptom patterns of women with a DUD to those with and without an AUD in a sample of women seeking residential substance use treatment. NPs in the primary care setting may be instrumental in screening women with a DUD who often suffer from a decreased quality of life,2,13 as well as comorbid psychiatric conditions, including major depressive disorder, dysthymia, social phobia, generalized anxiety disorder, and PTSD. Intervention strategies can be targeted at educating the patient about the importance of family/significant-other’s support and development of positive coping skills. If the patient has already stopped drinking, relapse prevention techniques, with the goal of assisting the women to remain sober, are also important. Self-help groups for the women and their family members should also be encouraged.9,30,31 The Journal for Nurse Practitioners - JNP

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CONCLUSION

The data presented highlight the need for NPs to conduct screening for co-occurrence of symptoms (eg, anxiety and psychoticism) among women who have both drug and alcohol disorders. The use of an appropriate screening tool can lead to rapid referral and targeted interventions related to the specific symptoms within the subgroup (ie, both AUD/ DUD). Future studies should utilize measures like the Alcohol Use Disorders Identification Disorders Test to obtain a measure of alcohol pattern, frequency, and current use.32 In addition, awareness of distress can lead to appropriate responses to ensure safety. Future studies should provide further insights into the special considerations, treatment needs, and ideal therapeutic strategies for individuals seeking SUD treatment who have both a DUD and an AUD. NPs should act as patient advocates for this vulnerable population to respond to the possible special considerations, treatment needs, and ideal therapeutic strategies for individuals with these dual problems. References 1. Hingson RW, Heeren T, Edwards EM, Saitz R. Young adults at risk for excess alcohol consumption are often not asked or counseled about drinking alcohol. J Gen Intern Med. 2012;27(2):179-184. 2. Kessler DA. Alcohol marketing and youth: the challenge for public health. J Publ Health Policy. 2005;26(3):292-295. 3. Ullman SE, Relyea M, Peter-Hagene L, Vasquez AL. Trauma histories, substance use coping, PTSD, and problem substance use among sexual assault victims. Addict Behav. 2013;38(6):2219-2223. 4. Price CJ, Herting JR. Changes in post-traumatic stress symptoms among women in substance use disorder treatment: the mediating role of bodily dissociation and emotion regulation. Subst Abuse. 2013;7:147-153. 5. Greenfield BL, Venner KL, Kelly JF, Slaymaker V, Bryan AD. The impact of depression on abstinence self-efficacy and substance use outcomes among emerging adults in residential treatment. Psychol Addict Behav. 2012;26(2): 246-254. 6. Johnson JE, Zlotnick C. Pilot study of treatment for major depression among women prisoners with substance use disorder. J Psychiatr Res. 2012;46(9): 1174-1183. 7. Hallgren M, Ahlin J, Forsell Y, Ojehagen A. Increased screening of alcohol habits among patients with depression is needed. Scand J Public Health. 2014;42(7):658-659. 8. Farris SG, Epstein EE, McCrady BS, Hunter-Reel D. Do co-morbid anxiety disorders predict drinking outcomes in women with alcohol use disorders? Alcohol. 2012;47(2):143-148. 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: American Psychological Association; 2000. 10. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, Md: Substance Abuse and Mental Health Services Administration; 2013. 11. US Department of Health and Human Services. http://www.hhs.gov/ash/oah/ adolescent-health-topics/substance-abuse/alcohol.html/. Accessed. 12. Centers for Disease Control and Prevention. Fact sheets—excessive alcohol use and risks to women’s health. http://www.cdc.gov/alcohol/fact-sheets/ womens-health.htm/. 13. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United

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Pamela Newland, RN, PhD, CMSRN, NRSA/NINR is an assistant professor at the Goldfarb School of Nursing at BarnesJewish College in St. Louis, MO. She can be reached at pamela [email protected]. Sarah Meshberg-Cohen, PhD, is a clinical psychologist and assistant clinical professor at the Department of Psychiatry at Yale School of Medicine and VA Connecticut Health Care System in West Haven, CT. Louise H. Flick, Volume 11, Issue 6, June 2015

DrPH, MSN, MPE, is a Emerita professor of epidemiology and nursing at the College for Public Health and Social Justice and School of Nursing of Saint Louis University in St. Louis, MO. Kate Beatty, PhD, MPH, is an assistant professor at the Department of Health Services Management & Policy of the College of Public Health at East Tennessee State University in Johnson City, TN. Judith Smith, RN, PhD, GCNS-BC, is

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an associate professor of nursing at the Goldfarb School of Nursing at Barnes-Jewish College. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.03.016

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