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JNSD Journal for Nurses in Staff Development & Volume 27, Number 5, 220Y226 & Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Pilot Testing an Educational Intervention to Improve Communication With Patients With Dementia Tina Weitzel, MA, RN-BC ƒ Sherry Robinson, PhD, GCNS-BC ƒ Sandra Mercer, DipN, RN, CEN, TNS ƒ Tammy Berry, BS, RN ƒ Mary Barnes, MS, BSN, RN, CCRN ƒ Dee Plunkett, BS, RN ƒ Charlene Vollmer, BSN, RN-BC ƒ Teresa Foster, BS, RN ƒ Lisa Friedrich, RN-BC, MSN ƒ Laurie Allen, BS, RN ƒ Jennifer Holmes, BSN, RN-BC ƒ Geri Kirkbride, MSN, RN, CCRN Approximately one quarter of all hospitalized patients over age 75 years have a secondary diagnosis of dementia. A unique hospital-wide program to encourage appropriate communication techniques with patients who have dementia was provided to all departments of a hospital. Evaluation indicated improvement in some communication techniques. Additional education is needed to disperse the information to as many staff as possible and to sustain the change. Tina Weitzel, MA, RN-BC, is Nursing Practice Development Facilitator and Coordinator of the NICHE Committee, Memorial Medical Center, Springfield, Illinois. Sherry Robinson, PhD, GCNS-BC, is Assistant Professor, School of Medicine, Southern Illinois University, Springfield. Sandra Mercer, DipN, RN, CEN, TNS, is Clinical Nurse III, Memorial Medical Center, Springfield, Illinois. Tammy Berry, BS, RN, is Clinical Nurse III, Memorial Medical Center, Springfield, Illinois. Mary Barnes, MS, BSN, RN, CCRN, is Nursing Faculty, St. John’s College of Nursing, Springfield, Illinois. Dee Plunkett, BS, RN, is Clinical Nurse III, Memorial Medical Center, Springfield, Illinois. Charlene Vollmer, BSN, RN-BC, is Clinical Nurse III, Memorial Medical Center, Springfield, Illinois. Teresa Foster, BS, RN, is Clinical Nurse II, Memorial Medical Center, Springfield, Illinois. D ementia is a serious illness affecting 5.2 million persons in the United States. Of all hospitalized patients over age 75 years, approximately one quarter have a secondary diagnosis of dementia. By 2040, the number of people with dementia will double, further increasing the number of patients hospitalized with a secondary diagnosis of dementia (Alzheimer’s Association, 2008a). Patients with dementia are much more vulnerable to the hazards imposed by the acute care environment. They are suddenly plunged into an unfamiliar environment with strange surroundings, noises, equipment, and people. They are confronted with high stimulus levels created by monitors, paging systems, electric beds, hallway noise, and alarms (Borbasi, Jones, Lockwood, & Emden, 2006). Often, the elder person with dementia becomes anxious and agitated, which usually is an expression of fear or an unmet need (Smith & Buckwalter, 2005). Adequate and effective communication with patients with dementia is crucial to care, whether the caregiver is a nurse, physician, laboratory technician, transporter, or any other member of the healthcare team. The purpose of this article is to describe a hospital-wide educational program developed to address proper communication techniques to use with older adults with dementia. Lisa Friedrich, RN-BC, MSN, is Clinical Nurse III, Memorial Medical Center, Springfield, Illinois. LITERATURE REVIEW Laurie Allen, BS, RN, is Clinical Nurse IV, Memorial Medical Center, Springfield, Illinois. Effect of Dementia on Communication Jennifer Holmes, BSN, RN-BC, is Administrative Supervisor, Memorial Medical Center, Springfield, Illinois. Geri Kirkbride, MSN, RN, CCRN, is Nursing Research Facilitator, Memorial Medical Center, Springfield, Illinois. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. ADDRESS FOR CORRESPONDENCE: Tina Weitzel, MA, RN-BC, Memorial Medical Center, 701 N. 1st Street, Springfield, IL 62781 (e-mail: email@example.com). DOI: 10.1097/NND.0b013e31822e0738 220 www.jnsdonline.com The anatomical and physiological changes in the brain associated with dementia result in problems with both receptive and expressive language. Various communication problems occur related to memory loss, decreased attention span, impaired judgment, decreased insight, decreased abstraction, and diminished visual/spatial abilities. Patients with dementia may have problems with word finding, repeating words over and over, and inventing new words to describe familiar objects (Alzheimer’s Association, 2000b; Perry, Galloway, Bottorff, & Nixon, 2005). These September/October 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. unique communication patterns may be understood by family members or routine caregivers, but the caregivers in the hospital may be at a loss to understand the meaning of the patient’s communication. The unfamiliar environment further hampers the patient’s ability to understand questions, follow directions, report symptoms, and call for help. Often, changes in behavior indicate fear or an unmet need such as hunger or pain or the need for toileting; thus, the elder person with dementia may become anxious and agitated (Alzheimer’s Association, 2008b; Frazier-Rios & Zembrzuski, 2007; Miller, 2008). Borbasi et al. (2006) conducted interviews with 25 medical, nursing, and other healthcare professionals to explore healthcare professionals’ experiences of managing patients who have dementia. One of the themes that emerged from the study reflected decreased attention to assessing the needs of patients with dementia. Staff had a tendency to avoid including the patient in discussions and assessments. These patients seemed to be stereotyped as unable to communicate and provide information. Thus, no attempt was made to solicit information from them for the assessment. Suggested Communication Techniques Ideally, communication techniques should be individualized depending upon the specific communication problem that each patient exhibits (Perry et al., 2005). Given that hospital stays are short and that many caregivers may have only a single interaction with the patient, it is difficult to know the individual techniques to use with each patient. However, experts in the field of dementia have recommended simple techniques that can be used by all types of caregivers with most patients who have dementia. Some of these include asking permission, keeping explanations simple, and using reminiscence. Asking permission helps prepare the patient for a procedure. Keeping explanations simple, asking questions slowly, and supplementing with simple gestures facilitate communication. Reminiscence can be effective because long-term memory is often retained. A complete list of techniques is listed in Table 1. Neutral Communication Hairon (2008) examined the experiences of 424 people with dementia who resided in residential homes and found many examples of excellent care but noted that the quality of communication was lacking. The most harmful form of communication was labeled a ‘‘neutral’’ style of communication, even more harmful than negative communication. This style was observed quite often and was demonstrated when staff simply ignored the patient and focused on a task. Failure to address the elder person denied acknowledgment of the elder as a person. The investigators noted that elders often appeared saddened and dejected after these interactions. They concluded Journal For Nurses in Staff Development that this neutral communication has a great impact on elders’ feeling of recognition of self-worth and reflects lack of respect. Most likely, hospital staff are not aware of the seriousness of this neutral communication. THE EDUCATIONAL PROJECT The impetus for this project was a letter written by an employee accompanying her mother, who had dementia, throughout the hospital stay. She was disturbed by the manner in which many staff communicated with her mother. It was apparent to the employee that most staff had little understanding of dementia and the associated communication problems. Many people questioned her mother in great detail, which caused the patient increased anxiety. Sometimes, staff gave multiple directions to her mother when she was undergoing tests. In the letter, the daughter suggested that all hospital staff would benefit from education about communication techniques for people who have dementia. The vice president of the hospital asked the Nurses Improving Care to Health-Systems Elders (NICHE) committee to focus on this issue. The NICHE committee is composed of 12 staff nurses from various nursing units, representing critical, intermediate, and acute levels of care. The committee includes a geriatric clinical nurse specialist and a nursing research facilitator. A geriatrician from the nearby school of medicine and members of ancillary services participate on an ad hoc basis. The purpose of the committee is to (a) identify opportunities to improve patient care and outcomes for elder patients, (b) Develop and implement initiatives to address best practice for identified issues, and (c) produce informal and formal educational programs to increase staff awareness of the increased risk for elder patients to develop ‘‘geriatric syndromes’’ that can negatively affect patient outcomes. Study Design A preYpost observational pilot study was developed to examine communication between staff and patients with dementia before and after the educational initiative. The study was approved by the local university institutional review board, and a waiver of informed consent was granted. The study population was a convenience sample of healthcare workers working with patients with dementia on one of the five medical, surgical, or medicalYsurgical nursing units at this facility. The inclusion criterion was any interaction with a patient with dementia. The only exclusion criterion was if the door to the patient’s room was closed during the interaction, as this would make it impossible for the observation to occur. Data collection occurred for 2-hour periods daily for 2 weeks. These sessions occurred on both the day (7Y3) and evening (3Y11) shifts. Because it was believed that patients would be asleep on the night (11Y7) shift, the decision was made not to collect data at night. www.jnsdonline.com Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 221 TABLE 1 Suggested Communication Techniques Technique Example Reference(s) Approach directly Approach directly and slowly, making eye contact with a pleasant expression. Patients with dementia are quite sensitive to others’ emotions and respond more to the manner in which others speak rather than to the actual content of the message. Their stress level will mimic the staff member’s stress level. It is critical to approach them in a calm pleasant manner. Alzheimer’s Association (2008b), Hall (1991), Smith, Hall, Gerdner, and Buckwalter (2005) Use full name Staff should call elders by name, addressing them as Mr., Mrs., Alzheimer’s Association (2008b), Hall (1991), Smith et al. (2005) or Miss and refrain from using terms like Honey or Sweetie. Staff should introduce themselves with each interaction, providing their name and their title. For example, ‘‘I am Jane Smith and I am the nurse taking care of you today.’’ Respect personal space Smith et al. (2005) For the patient with dementia, personal space may be very large. Staff should initially extend their hand to the patient and express a greeting. A patient with dementia who reaches readily to shake hands generally responds well to touch. Ask permission Caregivers need to ask permission to examine or perform a procedure. For example, a nurse needing to take a blood pressure should say, ‘‘Mrs. Jones, may I please take your blood pressure?’’ Give positive feedback Giving positive feedback and thanking the patient will generally McCloskey (2004), Stolley et al. (1993) improve the acceptance of a procedure or an examination For example, the nurse might say, ‘‘Thank you for letting me take your blood pressure, Mrs. Jones. It really helped me to take care of you.’’ Keep questions simple Questions should be asked simply and slowly and can be supplemented with simple gestures. ‘‘Yes’’ and ‘‘no’’ questions may be most effective. Staff should wait 15Y20 seconds for the patient to respond. If needed, the caregiver should repeat the question, using the same words. Avoid pronouns Caregivers should avoid using pronouns or indirect references. Smith and Buckwalter (2005) For example, the nurse should say, ‘‘Let me help you sit in the chair’’ rather than ‘‘Let me help you sit over there.’’ Avoid saying ‘‘don’t’’ Staff should avoid using the word don’t. This may cause the patient to feel disrespected and reprimanded. For example, instead of saying ‘‘Don’t get out of bed,’’ say ‘‘Please stay on the bed.’’ Smith and Buckwalter (2005) Avoid orientation questions Avoid quizzing the patient with orientation questions that cannot be answered. Most patients with dementia have lost short-term memory and will become frustrated with questions regarding person, place, and time. Smith et al. (2005) Reality orientation may not be helpful Reality orientation may not be useful and may increase stress and anxiety. Telling patients they are in the hospital and must have treatments done will not make them more cooperative. Asking permission and providing a simple explanation for procedures is often more effective. Smith et al. (2005) Reminiscence sometimes helps Reminiscence is an effective communication technique to use with elders with dementia because they often retain long-term memory. The nurse can ask simple questions about the elder’s past. Reminiscence helps to overlap the past, present, and future time spheres and helps reduce stress. Puentes (1998) Alzheimer’s Association (2008b), McCloskey (2004) Alzheimer’s Association (2008b), Hall (1991), Stolley et al. (1993) Continued 222 www.jnsdonline.com September/October 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. TABLE 1 continued Technique Example Reference(s) Direct conversation toward the patient If family members are present during communication, staff should direct the conversation toward the patient. Otherwise, the patient may become suspicious and angry. Listen closely Hall (1991), Puentes (1998), A few words in the conversation may give the staff a hint of Smith and Buckwalter (2005) what the patient with dementia is trying to convey. Family members often can decipher bizarre words or behaviors that are grounded in the patient’s past experiences. Each morning of the data collection period, the charge nurses were asked to identify patients with a primary or secondary diagnosis of dementia. Data collectors told the charge nurses only that they would be gathering data from patient records. The charge nurses and unit staff were acquainted with the data collectors, who frequently gather quality improvement data. If, at any time, unit staff asked the data collectors what information they were reviewing, the response was ‘‘quality improvement audits.’’ This process, identified as ‘‘covert data’’ collection, is defined as ‘‘the collection of information without the participants’ knowledge’’ (Polit & Beck, 2004, p. 148). Most patient rooms can be seen from some area of the nurses’ stations. The data collectors positioned themselves Hall (1991) where the room of the dementia patient could be visualized. When a healthcare worker was about to enter the room, the data collector moved immediately outside the door and listened to staff/patient interactions. The data collectors pretended to be reviewing the patient’s record but were actually listening to the communication techniques used by the staff member. To maintain confidentiality, no name, department, or other descriptors were recorded on the data collection instrument (see Table 2). Each interaction between a patient and a worker was treated as a separate observation. Data collectors recorded only the use of appropriate and inappropriate communication techniques using hash marks to indicate when a technique was used. If multiple TABLE 2 Observation Instrument For each interaction with a member of the health team, record a check by the communication techniques used during the interaction. Health Professionals Communication Technique #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 1. Identified himself or herself 2. Addressed the elder by Mr. or Mrs. 3. Addressed the elder by his or her first name 4. Explained what he or she was going to do 5. Asked permission from the elder to examine the elder or perform a procedure 6. Talked in a warm-pleasant, low-pitched manner 7. Used simple direct wording with short sentences 8. Talked in a loud voice 9. Told the elder what he or she could or could not do 10. Asked a lot of questions that relied on memory 11. Used reality orientation 12. Used reminiscence 13. Thanked the elder when the task was completed Journal For Nurses in Staff Development www.jnsdonline.com Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 223 techniques were used during the same observation, each technique was marked. The absence of a hash mark indicated that a particular technique was not used during that specific observation. All data collection was completed by NICHE members. Prior to initiation of data collection, the NICHE committee discussed the definition and examples of all communication techniques identified on the data collection tool and discussed the study methodology. Members were given the opportunity to ‘‘practice’’ introducing themselves and explaining their presence on the nursing unit. To avoid potential bias, data collectors did not observe on their own nursing units. The Educational Intervention After collection of the preintervention data, the NICHE committee developed a 12-minute educational video. The goal was to educate staff about the difficulties experienced by hospitalized elders with dementia and use of communication techniques to improve interactions. To be effective, the teaching method was designed to relate to the various types of learners and targeted nursing and other departments with direct patient contact including dietary, lab, X-ray, therapy, and others. On the basis of the literature, the NICHE committee’s gerontological clinical nurse specialist developed a scenario depicting staff from various departments interacting with a patient with dementia. The hospital’s media resources director produced and taped the production in a DVD format. The medical school provided a professional patient with experience in portraying a patient with dementia. Employees from nursing, laboratory, radiology, environmental services, and nutrition volunteered to act in the video. The scene was a hospital room where the patient with dementia was lying in a hospital bed calling out ‘‘help me’’ and ‘‘where’s my mama.’’ Various employees used inappropriate communication techniques as they entered the room to provide meals, start IVs, draw blood, clean the room, and perform X-rays. The patient responded with anxiety and agitation. The scenario was then repeated demonstrating proper communication techniques. The patient was less anxious and cooperated with care. A narration by one of the NICHE members was incorporated into the scenarios, providing background information on dementia and emphasizing appropriate communication techniques. A copy of the DVD was distributed to managers of all departments having direct patient contact. Managers were asked to show the DVD in staff meetings, and NICHE members presented the DVD at nursing-unit-based Council meetings during the next 2 months. The NICHE members also presented the DVD with an accompanying lecture at the annual local NICHE conference on dementia. 224 www.jnsdonline.com EVALUATION Six months after the DVDs were distributed, the NICHE committee conducted additional observations to evaluate the initiative. The same data collectors were used, and procedures were consistent with those used preintervention. Data were collected during 86 preintervention and 80 postintervention observations. Data were analyzed using descriptive statistics. The frequencies of each technique used by the preintervention group and the postintervention group were determined. The communication techniques used in each group were then compared by using chi-square. Table 3 displays the frequencies and percentages of the appropriate communication techniques emphasized in the education program. Table 4 displays the data regarding the inappropriate techniques. As can be seen in Table 3, the percentage of appropriate techniques improved. Five communication techniques were significantly improved. Three techniques improved somewhat but did not reach statistical significance. As can be seen in Table 4, use of most inappropriate techniques declined slightly, but none reached statistical significance. On many of the data sheets, observers had written comments that elders were being addressed as ‘‘Sweetie,’’ ‘‘Honey,’’ and other terms of endearment. Although no evaluation tool of the presentation was included with the DVD, informal feedback was provided TABLE 3 Use of Appropriate Communication Techniques Communication Technique Group 1 Group 2 (n = 86) (n = 80) p Identified himself/herself 34 (40%) 42 (53%) .094 Addressed the patient as Mr., Mrs., Miss 18 (21%) 32 (40%) .007* Explained what he/she was going to do 58 (67%) 64 (80%) .067 Asked permission to examine the elder/perform a procedure 19 (22%) 46 (58%) G.001* Talked in warm/pleasant manner 72 (84%) 70 (88%) .489 Used simple direct wording 52 (60%) 72 (90%) .006* Used reminiscence .002* 4 (5%) 16 (20%) Thanked the elder when the 13 (15%) 40 (50%) G.001* task was completed Note. Group 1 refers to the preintervention group, and Group 2 refers to the postintervention group. *p G .05. September/October 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. TABLE 4 Use of Inappropriate Techniques Group 1 Group 2 Communication Technique (n = 86) (n = 80) p Addressed elder by first name 25 (29%) 18 (23%) .334 Talked in a loud voice 12 (14%) 12 (15%) .848 Told elder what he or she could/could not do 11 (13%) 12 (15%) .681 Asked a lot of questions that relied on memory 10 (12%) Used reality orientation 28 (33%) 16 (20%) .067 6 (8%) .228 Note. Group 1 refers to the preintervention group, and Group 2 refers to the postintervention group. from three departments. They described it as ‘‘so true,’’ ‘‘just as it happens in the hospital,’’ and ‘‘the way it was presented will help me remember.’’ Feedback from the NICHE conference included ‘‘The video is one of the best CDs we have to present to staff’’ and ‘‘The video was excellent.’’ IMPLICATIONS The educational program did have a positive impact. Healthcare workers are using six of the seven appropriate communication techniques more frequently. More staff ask permission to examine or perform a procedure and thank the elder when the task is completed. These communication techniques convey respect and should be used with all elders. Even though there was significant improvement in how patients were addressed, too many staff continue to use neutral communication as described by Hairon (2008). Only 40% of staff addressed patients as Mr., Mrs., or Miss. Failure to acknowledge the elder as a person can be very harmful. Some patients were addressed as ‘‘Sweetie’’ or ‘‘Honey.’’ Staff possibly do this out of compassion for the elder, not realizing that they are actually infantilizing the individual, which is a form of psychological mistreatment. Infantilization is defined as patronizing treatment of older adults by caregivers who relate to them as a parent might to a child using baby talk (Salari, 2006). These terms may be perceived negatively by the person with dementia, who already is suffering from dependency and decreased selfesteem. Most adults, regardless of their cognitive status, prefer to be addressed in a manner that reaffirms that they are still competent (Salari, 2006). Use of reminiscence increased, whereas reality orientation decreased. More staff need to understand the usefulness of talking with patients who have dementia about Journal For Nurses in Staff Development their past. Because many patients with dementia retain long-term memory and lose short-term memory, asking them questions about where they grew up, their family, type of work, and so on may provide some comfort. Evidence supports the use of reminiscence to improve mood and well-being (Woods, Spector, Jones, Martin, & Davies, 2005). Conversely, reality orientation, if handled improperly, can create a challenge for the patient with dementia and can turn into a confrontation. Elders may feel they are being corrected or their deficits are being exposed (McCloskey, 2004; Smith et al., 2005; Woods, 2002). Although the data collectors in the study did not record quantity of communication between staff and patients with dementia, research indicates that staff generally communicate less to patients with dementia. Staff assume that these patients cannot understand or provide reliable information. CONCLUSION This pilot test is the beginning of transforming the hospital to a more dementia-friendly institution. Evaluation of the initiative was limited. Even though a DVD was provided to every hospital department, we cannot be sure that the staff we observed posteducation had actually seen the DVD. It is likely that only a portion of all staff viewed the DVD. In addition, we did not develop a structured presentation and discussion format for showing the DVD and we did not ask staff for formal feedback after viewing was complete. We are currently devising additional methods to provide this education to all staff and to new employees. To help sustain the intervention, a monthly communication tip will be included in the hospital newsletter, which is available to all staff. Evaluating the limitations of this pilot study informs the design of future research studies. With the burgeoning aging population, communication skills to interact with patients with dementia will become critical for all hospital employees. References Alzheimer’s Association. (2008a). 2008 Alzheimer’s disease facts and figures. Retrieved from http//www.alz.org/national/ documents/report_alzfactsfigures2008.pdf Alzheimer’s Association. (2008b). Communication. Retrieved from http//www.alz.org/living_with_alzheimers_communication.asp Borbasi, S., Jones, J., Lockwood, C., & Emden, C. (2006). Health professionals’ perspectives of providing care to people with dementia in the acute setting: Toward better practice. Geriatric Nursing, 27(5), 300Y307. Frazier-Rios, D., & Zembrzuski, C. (2007). Communication difficulties: Assessment and interventions in hospitalized older adults with dementia. Try this: Best practices in nursing care for hospitalized older adults with dementia. Retrieved from www.hartfordign. org/trythis Hairon, N. (2008). Improving communication skills in care of those with dementia. Nursing Times, 104(23), 19Y20. Hall, G. R. (1991). This hospital patient has Alzheimer’s. American Journal of Nursing, 91(10), 45Y50. www.jnsdonline.com Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 225 Miller, C. A. (2008). Communication difficulties in hospitalized older adults with dementia. American Journal of Nursing, 108(3), 58Y63. McCloskey, R. M. (2004). Caring for patients with dementia in an acute care environment. Geriatric Nursing, 25(3), 139Y144. Perry, J., Galloway, S., Bottorff, J. L., & Nixon, S. (2005). NurseYpatient communication in dementia: Improving the odds. Journal of Gerontological Nursing, 31(4), 43Y52. Polit, D. E., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.). New York: Lippincott Williams & Wilkins. Puentes, W. J. (1998). Incorporating simple reminiscence techniques into acute care nursing practice. Journal of Gerontological Nursing, 24(2), 14Y20. Salari, S. M. (2006). Infantilization as elder mistreatment: Evidence from five adult day centers. Journal of Elder Abuse & Neglect, 17(4), 53Y91. 226 www.jnsdonline.com Smith, M., & Buckwalter, K. (2005). Behaviors associated with dementia. American Journal of Nursing, 105(7), 40Y52. Smith, M., Hall, G. R., Gerdner, L., & Buckwalter, K. C. (2005). Application of the progressively lowered stress threshold model across the continuum of care. Nursing Clinics of North America, 41, 57Y81. Stolley, J. M., Hall, G. R., Collins, J., Bleuer, N., Adrian, C., & Buckwalter, K. C. (1993). Managing the care of patients with irreversible dementia during hospitalization for comorbidities. Nursing Clinics of North America, 28(4), 767Y781. Woods, B. (2002). Reality orientation: A welcome return? Age and Ageing, 31, 155Y156. Woods, B., Spector, A. E., Jones, C. A., Martin, O., & Davies, S. P. (2005). Cochran review: Reminiscence therapy for dementia. Retrieved from www.cochrane.org/reviews/ September/October 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.