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September 2012, Volume 39, Number 5
Article
The Lived Experience of Men Diagnosed With Prostate Cancer
Kelly A. Krumwiede,
PhD, RN, and Norma Krumwiede, EdD,
RN
Purpose/Objectives: To investigate the lived
experience of prostate cancer from a patient perspective.
Research Approach: Descriptive, qualitative.
Setting: Community setting.
Participants: 10 men with prostate cancer
aged 62–70 years.
Methodologic Approach: A hermeneutic phenomenologic
method using semistructured, open-ended questions
addressing the lived experience.
Data Synthesis: Phenomenology of praxis
proposed by van Manen guided the data analysis and
transformed personal experiences into disciplinary understanding.
Findings: The use of van Manen’s method of inquiry and analysis has contributed to
the findings of the study by providing a way to explore the meaning of the
lived experiences in an attempt to understand living with prostate cancer.
Several themes were identified: living in the unknown, yearning to understand
and know, struggling with unreliability of body, bearing the diagnosis of
cancer, shifting priorities in the gap, and feeling comfort in the presence of
others.
Conclusions: Oncology nurses can use van
Manen’s four fundamental existentials—lived
space (spatiality), lived body (corporeality), lived time (temporality), and
lived other (relationality)—to understand the lived
experience of prostate cancer. Nurses have many opportunities to impact the
lives of men diagnosed with prostate cancer, including diagnosis, management of
physical integrity, management of psychosocial integrity, and providing
education.
Interpretation: Nurses may encourage men to
describe their diagnosis story and illness experience to better understand the
meaning of the prostate cancer experience and to provide appropriate nursing
care.
Prostate
cancer is the second most common type of cancer among men and the second
leading cause of cancer-related death for men in the United States. In 2012, an
estimated 241,740 new cases of prostate cancer will be diagnosed in the United
States and about 28,170 men will die from the disease (American Cancer Society
[ACS], 2012). Although prostate cancer is most commonly diagnosed in men aged
65 years and older, the incidence begins to rise at age 50. ACS (2012)
estimates that 1 in 6 men will be diagnosed with prostate cancer during their
lifetime. Fortunately, prostate cancer diagnosed early is highly treatable. To
date, more than two million men in the United States have lived the prostate
cancer experience (ACS, 2011).
Exploring
the perceptions and experiences of men with prostate cancer will expand nurses’
understanding of the disease, as well as the responses, coping mechanisms, and
concerns that are prevalent. The purpose of this article is to investigate the
lived experience of older men who have been diagnosed with prostate cancer.
Methods
Phenomenology
is the thorough, systematic study of human experience that aims to produce
insightful descriptions of the way people experience their world (Creswell,
2009). Phenomenologists believe that knowledge and understanding are embedded
in everyday life, and that truth and understanding can emerge from life
experiences, which comprise thoughts, feelings, values, emotions, purposes, and
actions (Burns & Grove, 2009). The hermeneutic phenomenologic
structure for van Manen’s (1990) human science
research consists of six steps: (a)
turning to a phenomenon which seriously interests us and commits us to the
world, (b) investigating experience as we live it rather than as we
conceptualize it, (c) reflecting on the essential themes that characterize the
phenomenon, (d) investigating experience as we live it rather than as we
conceptualize it, (e) maintaining a strong and orientated caring relation to
the phenomenon, and (f) balancing the research context by considering the parts
and the whole.
The
semistructured interview technique used in this
article was guided by van Manen’s (1999) approach as
a way to gain access to the lived experience of men with prostate cancer. The
interview method provided a means for exploring and gathering experiential
narrative material that served as a resource to derive meaning of the lived
experience.
Sample and Setting
After
approval was granted from the institutional review board at Bethel University
in St. Paul, MN, the first participant was identified and the snowball
technique was used to obtain a convenience sample of 10 men with prostate
cancer. Participants were Caucasian, English-speaking adults ranging in age
from 62–70 years with a mean age of 66.2 years. Time since diagnosis ranged
from a few months to five years, with the mean being 2.4 years. One participant
received hormone therapy followed by radiation treatment, and the remaining
participants had radical prostatectomy, four of which had the robotic radical
prostatectomy procedure. Except for one participant who was divorced, the
participants were married and had supportive spouses and family.
Data Organization and Analysis
Phenomenology
of praxis proposed by van Manen (1999) guided the
data analysis and transformed personal experiences into disciplinary
understanding. Van Manen’s four fundamental existentials of lived space (spatiality), lived body
(corporeality), lived time (temporality), and lived other (relationality)
describe the way humans experience the world. These life world existentials acted as guides for reflection and were used
to guide the analysis of the data (see Table 1).
These four existentials can be differentiated but not
separated—they form an intricate unity van Manen
(1990) called “our lived world.”
Rigor
was enhanced by sensitivity, or a researcher’s ability to identify subtle
nuances and cues in the data text that lead to meaning. Sensitivity allows a
researcher to become immersed in the data in hopes of presenting the view of
participants (Creswell, 2009). Trustworthiness of the data and rigor were
established through credibility, dependability, transferability, and confirmability as described by Lincoln and Guba (1985). Credibility was established through extended
immersion, bracketing, and use of triangulation. Bracketing is a process of
identifying and setting aside one’s lifeworld beliefs
and biases, therefore allowing the researcher to be open to data as they are
revealed. All interviews were audio recorded, transcribed, and subsequently
analyzed to ensure dependability. Transferability was established through the
use of member checks. An extensive audit trail was created to ensure confirmability.
Findings
Six
themes and corresponding subthemes were identified during data analysis and are
representations of the narrative stories shared by the participants: living in
the unknown, yearning to understand and know, struggling with unreliability of
body, bearing the diagnosis of cancer, shifting priorities in the gap, and
feeling comfort in the presence of others. The six themes were identified
during data analysis and are representations of the narrative stories shared by
the participants. Figure 1 contains the themes
and subthemes of the lived experience for men with prostate cancer.
Lived Space (Spatiality)
Lived
space comprises two themes that have an impact on the day-to-day life
experience of men with prostate cancer: living in the unknown and yearning to
understand and know. The main findings associated with living in the unknown were
being vigilant; the findings associated with yearning to understand and know
were seeking and sharing information and measuring and comparing.
Living in the Unknown
Living
in the unknown affects the participant’s lived space of how a person perceives,
lives, and deals with day-to-day life. When the participants voiced not having
answers to questions or a clear direction of which to guide one’s life, this
precarious state of confusion and living in an unfamiliar environment caused
the participant to experience varying degrees of anxiety. Living in this
indeterminate state can cause worry and fear. Being told of a possible cancer
diagnosis brings the future into question. After having treatment, the patient
may wonder about the reoccurrence of cancer. The theme of living in the unknown
emerged as participants spoke of receiving different information about
prostate-specific antigen (PSA) readings, fear of
misdiagnosis, and unpredictability of the cancer experience.
Four
of the men expressed concern that a prostate cancer diagnosis could be missed,
overlooked, or incorrect. For example, one participant questioned whether his
prostate cancer diagnosis was correct. He received confusing information after
surgery.
The medical staff took my prostate out and sliced it
up into a hundred pieces and looked at it under a microscope and said that they
could not find any cancer. So does that mean that I didn’t have to have this
[surgery] done? Or does that mean that I should be thankful that I don’t have
cancer?
This
participant had signs of prostate cancer, including a PSA
reading that rose from 5 to 10.3 in one year and one of the biopsy specimens
had determined a diagnosis of cancer. Why then, in his mind, was he told after
having the prostate removed that it was not cancerous? Unanswered questions
such as this can be bewildering to patients, promoting distrust in the
healthcare system and causing men to live in the unknown.
Being
vigilant: Vigilance
is how the participants learned to live in the unknown. Being vigilant consisted of
watching, monitoring, and preparing oneself in relation to one’s condition. All
of the men had received information about their PSA
readings; however, the information the men received seemed to conflict with
what they heard from other men in the community.
One
participant questioned whether his physician had missed the diagnosis of
prostate cancer the year prior. The participant felt angry and stated more than
once during the interview that “men should have a proficient physician who does
a thorough exam[ination],
including a thorough digital exam[ination] and not
just a quick finger sweep.” The most effective screening methods include both PSA and digital rectal examination. Biopsy of the tissue is
used to diagnose prostate cancer.
Although
all of the participants acknowledged their survival and good outcome of the
prostate cancer treatment, many of the men revealed lingering thoughts about
the chance of recurrence. This unpredictability of prostate cancer and
recurrence of the disease instills fear of the “missed cancer cell.” Although
this uneasy feeling of the unknown exists, the men are determined not to live
the rest of their lives in fear. With the unpredictability of recurrence, the
participants have developed a new meaning for the PSA
readings. The readings are no longer a screening for prostate cancer, but a
sign that they made the right choice and are free of prostate cancer. The men
now find comfort and hope in having low to undetectable PSA
readings.
Yearning to Understand and
Know
In
the quest to develop an understanding, the participants often looked to other
men who have had the same experience and to nurses for honest and accurate
information. This yearning for answers to all of their questions was revealed
in the longing for understanding and the ability to make sense of one’s
situation. Once the participants were able to understand one or more aspects of
the prostate experience, the men were able to continue their life’s journey.
Seeking and sharing
information:
Participants desired to understand and know what was happening within their
bodies. Several of the men became proactive after their diagnosis and began
seeking information to learn more about prostate cancer and its treatments.
Participants looked for answers as a way to alleviate their anxieties, to
achieve a sense of comfort, and to provide a sense of stability. Many searched
for information on the Internet, from friends or family, and all received
information from their physician. Participants indicated that gaining a better
understanding of their situation helped them in decision making, particularly
about treatment choices.
Many
talked about seeking information from others who had gone through this
experience as being supportive, alleviating fears, and having an enormous
impact on the decision-making process. Even if the information was negative,
participants felt more secure knowing. The information shared provided
reassurance that the prostate cancer experience contains common reactions—that
others have gone through it and they can, too.
Promoting
awareness was important to all participants. With prostate cancer being so
common among men yet “so easy to take care of,” many individuals expressed a
strong desire to promote prostate cancer awareness and encourage men to seek
information on prostate cancer. Most men expressed the desire for others to
have the knowledge that they did not have when they first started their
experience.
Measuring and comparing: The ability of all
participants to use stories and compare notes in an attempt to observe or
discover similarities or differences was a central theme that allowed the
individual to measure one’s situation against that of others. The stories of
men with prostate cancer allowed the participants to determine whether they
were better or worse off than other men in this situation. Despite the fact
that each participant’s experience was significant, in the end many of the
participants felt that their experience had not been as bad as others.
Lived Body (Corporeality)
The
main theme for lived body is struggling with unreliability of body. The main
findings associated with lived body are enduring and conquering distressing
discomfort and concern for changed sexual expression.
Struggling With
Unreliability of Body
The
participants felt discomfort with the sensation of being disassociated from
their bodies. Often times, participants thought that they were healthy and “didn’t
have any problems” until the diagnosis was made. An unfamiliar sense of being
disconnected with oneself arose in the participants. One, for example,
wondered, “How can I have this, I feel so good?” Not knowing that they had
cancer inside their body was unsettling. Another participant described prostate
cancer as “like ovarian or breast cancer in women. It is very silent.” For the
men in this study, prostate cancer was a disease that did not make its presence
known and, for one of the men with the disease, was already outside the
prostate when cancer was discovered.
Enduring and conquering
distressing discomfort: The course of the disease requires men to hold up under multiple
stress-provoking situations. All of the participants were physically and psychologically
affected by the diagnosis of prostate cancer and treatments they endured. One
individual had androgen deprivation therapy and then radiation treatment; the
other nine participants had radical prostatectomies, four of whom had the
robotic radical prostatectomy procedure. All of the participants experienced
complex side effects. The side effects from androgen deprivation therapy
included hot flashes, diaphoresis, fatigue, depression, and erectile
dysfunction. The individual who had radiation experienced burnt skin, fatigue,
diarrhea, and occasional nausea. The men who had a prostatectomy experienced
brief or prolonged episodes of incontinence, impotence, erectile dysfunction,
and/or loss of libido. The two most significant negative outcomes of surgery
included incontinence and erectile dysfunction. Dealing with incontinence and
sexual dysfunction was difficult for these men and caused humiliation and
shame.
A
significant finding was the impact the urinary catheter had on the individuals
who elected to have surgery. The most difficult emotional experience, according
to one participant, was having urinary leakage around this catheter tubing. The
stress and embarrassment led to social withdrawal. The catheter was a constant
reminder of the prostate cancer and served as a threat to hope.
The
men were aware of postoperative catheter treatment but were emotionally
unprepared for the effects. Many participants described the catheter as the
worst part of the experience. Having the catheter in place for 10–21 days on
average, they developed a sense of “putting up” or “dealing with it.” The men
feared pulling the catheter out at night, and endured bladder spasms as the
antispasmodic medications prescribed often failed to prevent or decrease the
discomfort.
Removal
of the catheter was distressing for the participants, as they often experienced
urinary incontinence for the first time. A few discussed the embarrassment of
having to purchase urinary pads. Short-term incontinence was experienced by all
participants in this study—two continue to struggle with urge incontinence—and
all suffer from stress incontinence. Although the men had been warned to expect
decreased control, actually experiencing it was stressful and embarrassing.
Concern for changed sexual
expression:
Sexuality and sexual expression are very personal issues. All the participants
in this study discussed aspects related to their sexuality in the context of
sexual function following treatment for prostate cancer. Loss of erectile
functioning was significant to most men in this study, although they varied a
great deal in response to the experience. In this study, two of the nine men
who had had prostatectomies experienced erectile dysfunction following
treatment.
Most
of the participants experienced significant impairment regarding sexual
functioning, although this did not appear to be as significant of a problem
compared to incontinence. For one of the participants, erectile dysfunction
involved adjusting his thinking and appreciating other aspects of life. A few
of the men felt more sympathy toward their spouses; they felt their spouses
were the ones greatly impacted by the sexual dysfunction.
Lived Time (Temporality)
Bearing
the diagnosis of cancer and shifting priorities in the gap are the two themes
related to lived time. With bearing the diagnosis of cancer came troubled
waiting. With shifting priorities in the gap, participants developed an
awareness and appreciation for living and were living in the present with an
eye toward the future. Prostate cancer and its treatments are an experience in
time.
Bearing the Diagnosis of
Cancer
The
participants described the intense, life-altering experience of being diagnosed
with prostate cancer. The turmoil that a person experiences from the initial
physician’s appointment and waiting for test results to be completed is one of
intense waiting. The participants varied in their reactions of being diagnosed
with prostate cancer: some were totally surprised, one
stated that he was in denial, and others were anticipating the diagnosis.
However, all the participants had to bear the vulnerability of being diagnosed
with prostate cancer.
One
participant stated he did not get “freaked out” when he was told he had cancer
but thought, “This is really weird. Cancer is in my body. It is like a pimple
that you would like to squeeze and get rid of but you can’t touch it and it is
trying to kill you.” For many it was a shock to receive the diagnosis of
cancer. Another participant described his experience of being told that he had
prostate cancer as, “It was sort of a surreal time for me.” Yet for one of the
participants, the diagnosis was “not a surprise,” as he said that his three
brothers and his father all had been diagnosed with prostate cancer. Although a
few participants were not surprised by the diagnosis, periods of waiting were
present for all the participants during this phase of the experience.
Troubled waiting: Diagnostic confirmation
takes a few days. This lapse in time caused many men to become anxious about
the diagnosis and the threat of potential side effects from treatments. In
addition, the potential for death caused emotional distress. Time seemed to
stand still when some of the participants received information about their high
PSA reading and their biopsy results and before they
started treatment. One participant stated, “The two days [after] the biopsy
were probably the longest two days of my life.” Most of the men stated it was a
shock to hear the diagnosis of prostate cancer. Although being diagnosed with
prostate cancer is a traumatic event, most of these men were told of options
for treatment directly after receiving the diagnosis. Their first reaction was
just to get rid of the cancer. Some did not want to hear all of the treatment
options and went straight to requesting a prostatectomy. Waiting for treatment
to start caused a great deal of anxiety for the participants.
Shifting Priorities in the
Gap
The
gap (time spent waiting for screening results, biopsy results, and treatment to
begin) affects a person’s lived time and causes a break in past, present, and
future priorities. Feelings of having a positive attitude and the desire to
appreciate one’s life and the lives of those around them developed. Patients’
altered perspectives of themselves and of life manifested in several ways. Many
patients underwent a reevaluation of their values, beliefs, life goals, and
priorities. One participant described a positive moment in his experience as
learning “to respect health and the maintenance of health and not to take
things for granted.” Another participant mentioned that prostate cancer had an
impact on his outlook on life. He stated that life has “a whole different
meaning. . . . You live each day to the upmost and you do things you can do when
you can. You just have a whole different philosophy of life.”
Developing
an awareness and appreciation for living: Cancer is an experience that affects all
aspects of a person’s life in ways that people without cancer cannot begin to
imagine.
The experience caused the participants to prioritize the people and things that
are most important to them. As a result, they were compelled to evaluate their
lives and to incorporate the experience of cancer into their understanding of
themselves. The experience of prostate cancer can stimulate a renewed
appreciation for living. The participants learned not to take life for granted,
and past and current struggles do not seem as important because they survived
cancer. One participant felt God was telling him to let go of his bitterness
and that he was given another chance at life. Thinking positively was a
significant aspect in participants’ ability to appreciate and live life.
Living in the present with
an eye toward the future: The participants’ uncertainty allowed for wondering what the future will
hold and a desire to live life to the fullest. Being determined to enjoy their
lives in the present despite being diagnosed with prostate cancer had a
positive impact on the men’s outlook on life. Life goals were not diverted, only shifted. The men were determined to enjoy
life by spending more time with family, golfing, helping others, gardening, or
fishing.
Having
an eye toward the future has been a result of the removal of the prostate
cancer. For the nine participants who had had prostatectomies, the fear of
having prostate cancer again has been eliminated. The prostate had been removed
and is no longer a factor in the equation. However, the men realize they need
to make each day count and enjoy what they have, particularly in regard to
their relationships with others.
Lived Other (Relationality)
The
theme of feeling comfort in the presence of others is the relationship that men
with prostate cancer maintain with family members, peers, healthcare workers,
and a higher power. Men spoke of feeling comfort through the development of
trusted connections and the unwaivering support they
received throughout their experience with prostate cancer.
Feeling Comfort in the
Presence of Others
This
theme best describes the essence of how these participants viewed their
relationships with others. The men gained strength and confidence through the
support of others. Some did not feel that they would have been able to make it
through the experience without that support.
Trusted connections: Connections were made with
healthcare providers, friends, and family. Having a trusted relationship with
one’s healthcare provider had a significant impact on the men’s comfort level
during their experience. Open communication and receiving all of the facts from
physicians and nurses created a trusting relationship. However, inconsistent
nursing care (i.e., not responding to needs in a timely manner, not appearing
competent in the treatment process, and not communicating in a caring manner)
placed a strain on the nurse-patient relationship. More than one participant
commented on how the nursing shortage impacted confidence in the healthcare
system. Ultimately, the men felt devalued when inconsistent nursing care and
lapses in communication occurred. The opposite also proved to be true—the men
found comfort with consistent nursing care, open communication, caring nursing
attitudes, and the use of humor by nurses.
Unwaivering support: Many participants expressed gratitude for the
support they received from family and friends. One man felt that, “Family is
probably the biggest support you really need” during the experience. Having
support from your family seemed to bring about a sense of relief and comfort
about the treatment decision they made. Another participant stated, “My wife
was very supportive. She believed that I made the right choice even though
there was a risk of sexual activity loss and I was concerned about
incontinence.” The participant felt that family should support the treatment
decision and the couple should talk about the options together. One participant
also acknowledged that “it would be tough not to have any family . . . to go
through it on your own.” All of the married men indicated that the most
significant emotional and physical support was received from their spouse. The
support provided a sense of comfort and reassurance in their time of
uncertainty.
Discussion and Implications for Nursing
Oncology
nurses are concerned with providing holistic nursing care. Nurses must
understand the lived experience of prostate cancer to better care for these
men. Lived space (spatiality), lived body (corporeality), lived time
(temporality), and lived other (relationality) make
up the landscape by which people experience phenomena (van Manen,
1990).
Phenomenology as a Nursing
Practice Approach
Phenomenologic study identifies the essence of a phenomenon and describes it through
the lived experience. By using phenomenology to explore common events and
emotions, lived experiences of individuals can become meaningful to others.
Therefore, the lived experience of individuals with prostate cancer can now
inform nursing practice. To increase the nurse’s understanding of the lived
experience of prostate cancer, nurses must encourage men to describe their
diagnosis story and illness experience to gain meaning of the prostate cancer
experience and to understand the needs of the men.
Lived Space (Spatiality)
Nurses
have many opportunities to take a leadership role when interacting with men who
have prostate cancer. The men need accurate information about PSA prior to having the procedure done. Because they felt
the healthcare system did not provide consistent information, PSA levels caused confusion and uncertainty for these men.
In a study by Bailey, Mishel, Belyea,
and Stewart (2004), the authors found that the men in their study often were
confused about prostate cancer and the meaning of PSA
values.
The
men also needed more time to learn about the disease and absorb the shock of
their diagnosis before deciding on a treatment option. Although patients need
to hear about the possible treatments the day they receive their diagnosis of
prostate cancer, there should be a follow-up appointment at a later time
(preferably within a week) to discuss the various treatment-related side
effects, review what was discussed, and clarify any concerns that may have
arisen. In addition, a spouse and family members should be encouraged to attend
the appointments.
The
need for nursing support is great during this vulnerable stage (Fan, 2002).
Nurses should provide accurate, complete, and consistent information to help
patients understand the full implications of the disease process and all
treatment options, not just the treatment options available at the facility of
care.
Lived Body (Corporeality)
Prostate
cancer is a disease that threatens critical aspects of a man’s body.
Harrington, Jones, and Badger (2009) established challenges to the management
of physical integrity. All of the participants in the current study had the
common experience of bearing the diagnosis of cancer and treatment effects,
which often is associated with pain, urinary incontinence, sexual dysfunction,
emotional suffering, and threat of death. This was consistent with Maliski, Kwan, Elashoff, and Litwin’s (2008) work on symptom clusters in patients with
prostate cancer. Sexual dysfunction for most men in this study occurred
following treatment.
The
findings in this study are consistent with those from Crowe and Costello
(2003), where the authors discovered the men in their study were concerned
about the impact their sexual limitations were having on their spouses. A few
of the men felt more sympathy toward their spouses, feeling that they were the
ones greatly impacted by their sexual dysfunction. Therefore, it would be
important to replicate this phenomenologic study with
spouses.
Lived Time (Temporality)
The
troubled waiting caused a shared experience of restlessness and impatience and
threatened the psychosocial integrity of the men (Cummings, 2005). This sense
of troubled waiting discouraged all of the participants from undertaking the
active surveillance approach for their prostate cancer, although research
supports this method (Davison, Oliffe, Pickles, &
Mroz, 2009). Prostate cancer surgery means probable
incontinence and a loss of sexual functioning that can affect a man’s quality
of life. Nurses can try to help coordinate biopsies early in the week to avoid
a delay over a weekend for pathology to reoccur. This may help reduce the
troubled waiting. The participants reported great relief once something was
being done about the prostate cancer. Most of the men commented that they were
anxious, restless, and in a hurry to get the cancer out of their bodies.
Lived Other (Relationality)
Nurses
must be prepared to support the patient and his family throughout the cancer
experience. Men spoke of feeling comfort through the development of trusted
connections and the unwaivering support they received
throughout their experience with prostate cancer. All of the men indicated that
support from their family was important and that it allowed them to deal with
the difficult circumstances of prostate cancer. The support of family members,
friends, and healthcare workers was identified by the participants as an
important aspect of living with prostate cancer. Nurses need to be aware of the
impact of the cancer diagnosis and treatment on the man’s family as a supportive
unit (Eggenberger, Meiers, Krumwiede, Bliesmer, & Earle,
2011). All of the men, except for one who was divorced, had close relationships
with spouses who collaborated with them, worried with them, and provided
physical and emotion support during their experience. Because of the amount of
assistance received from spouses, nursing education and support should be aimed
at men and their spouse or an identified caregiver. The nurse should include
family members in all aspects of health care. Nurses also need to emphasize the
importance of the support system to help cope with the uncertainties of the
disease.
Conclusion
Based
on findings of the current study, the following recommendations are proposed to
enhance the nursing care provided to men with prostate cancer. Patients need to
be encouraged to take time to process the meaning of their diagnosis before
making any decision or having discussions with their spouse. Improved education
is needed for patients and must incorporate the men’s insights and experiences
during the treatment course. Nurses can use the four existential life worlds to
guide nursing actions. This approach to nursing care will incorporate the
meaning and understanding of the lived experience of prostate cancer and
individualize the patient’s care.
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Kelly A. Krumwiede,
PhD, RN, is an assistant professor and Norma Krumwiede,
EdD, RN, is a professor, both in the School of
Nursing at Minnesota State University in Mankato. No financial relationships to
disclose. Kelly Krumwiede can be reached at kelly.krumwiede@mnsu.edu, with copy
to editor at ONFEditor@ons.org. (Submitted November 2011. Accepted for
publication February 8, 2012.)
http://dx.doi.org/10.1188/12.ONF.E443-E450