Risk Models in Guiding Nurses

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Risk models are useful in guiding nurses in their work processes and application of knowledge in practice. Some researchers, however, have noted serious challenges in the way many guidelines are developed (Kerr, Meisner, Thiessen-Philbrook, Coca, & Parikh, 2015). Further, Kerr et al. (2015) have observed that some guidelines may not supply adequate information to allow readers to evaluate credibility of such guidelines.

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In the recent past, there is a massive growing interest in creating risk prediction models in medicine. However, researchers have noted that some risk models in various areas of studies have critical flaws or deficiencies in the manner in which they are developed and reported. Specifically, some risk models used in medicine have left out vital details, including strategies for handling and reporting missing data; useful information on the population of study; and the exact definition of the expected outcomes or elements of interests. In addition, a standard of measure, for instance, in some risk models is missing. Moreover, developers normally evaluate some risk models favorably when they validate them (Collins, Omar, Shanyinde, & Yu, 2013).

Notably, optimistic bias or optimism bias has often been cited in some risk prediction reports (Kerr et al., 2015). Regrettably, optimistic bias or optimism bias can be applied to reflect various types of challenges found in risk model development or evaluation. Thus, it would be imperative to create clear, unique, and descriptive attributes for various sources of bias that may influence scientific findings.

Kerr et al. (2015) have identified common sources of biases in risk mold as “model-selection bias and resubstitution bias” (p. 2). Resubstitution biases occur when the same data used in “a predictive model development and used in assessment of the model performance” (Kerr et al., 2015, p. 2). That is, the same data are used in a similar manner. On the other hand, a model -selection bias results when “models are assessed and the best yielding model is reported” (Kerr et al., 2015, p. 2).

Kerr et al. (2015) asserted that both model-selection and resubstitution bias are well known among researchers. On this note, the authors focused on developing a standardized terms to reflect various challenges noted in model development.

The authors noted that there was a technique for gauging the performance of a risk model based on the optimistic bias and resubstitution bias. These methodologies include “cross-validation, bootstrapping techniques and the use of independent datasets for risk model development and performance evaluation” (Kerr et al., 2015, p. 2). Kerr et al. (2015) observed that the model-selection bias is usually not easy to handle in the absence of independent validation dataset. Based on expected standards, researchers can combine a model-selection and make it a part of a bootstrapping or cross-validation technique. However, the approach needs an automated process. It also enhances the complexity of computational techniques.

The known used reporting standards in risk model development are mainly “REMARK, GRIPS, and STARD” (Kerr et al., 2015, p. 2). Kerr et al. (2015) proposed a RiGoR standard, which focuses on gauging patient risks of a binary result. The RiGoR is more robust, general and detailed relative to the previous models. It is also imperative to note that the researchers used the previous standards to develop the RiGoR standards.

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RiGoR standards account for a risk prediction model. It assesses and reports because calibration is necessary to ensure that the risk model is valid. Some standards lack calibration while RiGoR significantly accounts for resubstitution bias and model-selection bias.

The researchers clearly identified a phenomenon of interest as fatigue associated with chemotherapy (Spichiger, Rieder, Müller-Fröhlich, & Kesselring, 2011). Patients, however, do not always report their experiences to physicians. In addition, physicians rarely evaluated and treated such conditions. Hence, many cases of fatigue are unreported, unrecognized and untreated (Spichiger et al., 2011). Many patients engage in various forms of self-care without guidelines or known outcomes. In addition, the available information and findings on chemotherapy fatigue were published more than a decade ago. The study problem recognized changes in healthcare such as availability of information to patients and physicians’ practices, but there are no current studies to inform such developments (Jakobsson, Taft, Östlund, & Ahlberg, 2013).

To describe the phenomenon of interest, the researchers chose the Grounded Theory methodology. This methodology was intended to support qualitative study. The method of data collection was adequate to address fatigue and self-care activities among chemotherapy patients. Hence, the researchers could collect data and identify details to increase insights and develop concepts of the phenomenon.

Interview is a well-suited data collection methodology for researching phenomena of interests in qualitative studies. It captures participants, processes, activities, outcomes, and effectiveness of such activities in contextual situations. Consequently, researchers were able to explore “patients’ fatigue-related interactions with professionals during chemotherapy, patients’ strategies to deal with the symptom and the perceived outcomes of their self-care activities” (Spichiger et al. 2011, p. 166).

The study findings showed how patients were informed about fatigue and chemotherapy, and their experiences of symptoms (Spichiger et al., 2011). In addition, the researchers described factors that influenced participants’ experiences, fatigue as a process of treatment and support. Findings also reflected self-care activities and lack of communication between patients and physicians during treatment.

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Based on the previous findings, several patients reported getting insufficient preliminary information on chemotherapy-related fatigue from physicians and family members could not understand outcomes. Today, however, much published information is readily available to patients and the public on fatigue-related experiences from cancer chemotherapy. In addition, Spichiger et al. (2011) noted that patients in their study reported fatigue experiences similar to those identified in past studies.

Nevertheless, there were study limitations such as the sample was intentionally heterogeneous, sample size was limited, results were not discussed with patients, failure to achieve saturation and to develop a theory.

The conclusion provided a context in which to use the findings. The researchers showed that their findings should be implemented into clinical practice to “integrate evidence-based interventions against chemotherapy-related fatigue effectively into standard practice” (Spichiger et al., 2011, p. 170).

The study conclusion reflected the findings of the study. For instance, patients and families were informed of fatigue, patients did not sufficiently communicate with their physicians, physicians did not make follow-ups and patients did not understand why they chose some activities to cope with fatigue.

The researchers offered recommendations for future studies. They noted that such studies were necessary to “integrate evidence-based interventions against chemotherapy-related fatigue effectively into standard practice” (Spichiger et al., 2011, p. 170).

The significance of the study to nursing was explicit. The researchers challenged oncologists and oncology nurses to adopt available knowledge into care and recommended standardization of fatigue-related processes to overcome communication challenges noted between patients and physicians.

The article aimed to investigate three critical elements related to potential access to fast food.

  • Potential spatial access to fast food entrées and side dishes from traditional fast-food restaurants, convenience stores, and supermarkets/grocery stores in terms of proximity and coverage in Texas rural area
  • The potential spatial access to healthier fast food options
  • The relationship between neighborhood deprivation and spatial access to all fast food opportunities and to fast food opportunities that offer healthier options (Sharkey, Johnson, Dean, & Horel, 2011)

Families and individuals have significantly continued to depend on foods prepared outside their homes as substitutes for foods prepared at homes due to various factors related to economic and social issues, such as costs, convenience and time (Poti, Duffey, & Popkin, 2014). In this context, foods from fast food restaurants lead other sources of away-from-home foods. They also tend to be rich in energy, calories and fat. Such foods are linked to poor diets and obesity epidemic. Thus, it is imperative to understand individual-level consumption of fast food, food environment and their impacts on diets and health outcomes. In addition, several studies have established that the food environment landscape in socioeconomically and geographically disadvantaged areas were associated with ease of access and wider coverage or presence of fast food restaurants and small food stores, such as convenience and corner stores, than to supermarkets, which offer a selection of healthy foods at lower prices (Sharkey et al., 2011).

Sharkey et al. (2011) conducted a thorough review of available literature in their area of investigation and designed a study to respond to the gaps identified in the reviewed literature. They noted that previous studies focused on spatial access to retail grocery stores and presence of healthier fast food options, fast food restaurants and retail food stores in socioeconomically disadvantaged locations. Literature review also revealed that previous research had pointed out the link between high calorie and fat contents in fast foods, which led to widespread obesity epidemic.

Ground-truthed method of data collection was used in the study. It involved “marking and geocoding all fast food restaurants, convenience stores, supermarkets, and grocery stores within areas of the study” (Sharkey et al., 2011, p. 11).

From the study results, Sharkey et al. (2011) noted that “spatial access to fast food opportunities (FFO) was significantly better than traditional fast food restaurants (FFR) while the median distance to the nearest FFO was 2.7 miles, compared with 4.5 miles to the nearest FFR” (p. 10). In addition, people who stayed at high deprivation locations had better spatial access to different types of healthier fast food opportunities than people who stayed at low deprivation locations.

The researchers also noted that there was a significant increment in demand for foods prepared from external places other than homes. Fast food was the preferred choice for many residents. It was a leading source of away-from home consumption and was responsible for high-energy content foods, as well as obesity claims.

Sharkey et al. (2011) concluded that any attempts to refer to fast food restaurants as the only source of fast food opportunities failed to account for neighborhood exposure to fast food with regard to proximity and coverage. Therefore, the study implication was that any possible interventions had to account for “all retail fast food opportunities and traditional fast food restaurants” (Sharkey et al., 2011, p. 10).

India is important in the global health because it accounts for almost one-fifth of all noted maternal deaths globally (Mehta, Mavalankar, Ramani, Sharma, & Hussein, 2011). Thus, there have been important efforts to “reduce the rate of maternal mortality in India” (Mehta et al., 2011, p. 37).

One major aspect in India is to promote enhanced hospital delivery among women. Consequently, significant improvements in deliveries in hospitals have been recorded because of the “offered financial incentives to women and healthcare workers” (Mehta et al., 2011, p. 37). As the rate of hospital deliveries increases, women face increased wound and genital tract infections. Puerperal sepsis has been recognized as the most dangerous and life threatening (Mehta et al., 2011). Maternal deaths that result from puerperal sepsis are responsible for almost 15 percent, and they are only second to hemorrhage in India. In this regard, many researchers have been interested in understanding the current practices and procedures used in the control of infections in India based on observations in labor and delivery rooms. Some critical areas of focus have been health information management systems; cleaning practices; cleaning equipment; cleaning environment; and diagnostics and treatment (Patwardhan & Kelkar, 2011).

The article expressed that women in India have sought childbirth from health care facilities (Mehta et al., 2011). The researchers observed that women went to those health care facilities because of incentives from the government. This was important in reducing infections contracted from poor hygienic conditions, which resulted from home deliveries. However, they noted that poor infection at the hospital delivery wards and labor units also resulted in “puerperal sepsis and other infections of childbirth” (Mehta et al., 2011, p. 37). They conducted a need assessment in order to obtain “data for formulating effective procedures and practices related to control of infection from delivery rooms and wards in India” (Mehta et al., 2011, p. 37). The researchers conducted a study in 20 health care facilities, which also included private and public hospitals. Data concentrated methods of “controlling infections, cleaning guidelines and practices, cleaning equipment, environment, and subsequent treatment” (Mehta et al., 2011, p. 37).

Aspects of improved care are prevention and treatment of common infections in labor and delivery rooms. Hence, much attention has gone to “infection control during maternity services in order to achieve the country’s preferred rates of maternal maternity” (Mehta et al., 2011, p. 37). Mehta et al. (2011) found out that infection control in many delivery rooms in Gujarat did not meet the expected standards. For instance, many facilities did not have any systemic approaches to control infection. They lacked set procedures for records, data analysis and action plans for follow-ups. The problem has been compounded by “a lack of standard procedures and guidelines, infection control measures and poor collection of data, provision of feedback and audit reports” (Mehta et al., 2011, p. 37).

The study showed that there was a need to enhance cleaning processes and procedures in labor and delivery facilities. Changes would be helpful in cleaning systems, practices, procedures, and training. They noted that the state needed to guarantee “safe delivery of women who used health care facilities for deliveries” (Mehta et al., 2011, p. 37). Healthcare facilities in Gujarat can achieve the improve through establishing active hospital infection control committee; assessing the burden of postnatal infections; initiating training programs to enhance skills of nurses in infection controls; formulating and implementing protocols for infection control; and enhancing record keeping, data analysis and reporting to improve practices.

Surgical site infection (SSI) is common and considered as the second most rampant hospital related infection after the urinary tract infection (Genet, Kibru, & Tsegaye, 2011). The prevalence of these infections differs from country to country based on the extent of adherence to “procedures and processes for controlling infections in any healthcare setting” (Genet et al., 2011, p. 9). Infections are vital because they are regarded as imperative clinical indicators for quality of care provided and measures to combat infections. Infections are mainly determined by total contamination noted in hospital settings. In addition, factors such as the quality of indoor air; techniques applied when conducting operations; patients’ extent of exposure; inserted or implanted foreign objects; effectiveness of surgical preparation; and timing of antimicrobial prophylaxis all contribute to influence surgical site infections.

It is imperative for surgical wards and operating rooms to attain acceptable levels of performances. Thus, healthcare facilities should have a diverse range of infection control strategies by focusing on various factors that contribute to infections because effectively implemented control measures can assist in curbing the spread of surgical site infections.

In most cases, surgical site infections result from contamination of indoor air in operating rooms and surgical words (Genet et al., 2011). Thus, the researchers noted that surgical infections were on the increase in many health care facilities. The main sources of infections were mainly bacteria from the ORs and surgical wards in which indoor aid had contamination. These researchers argued that microbiological quality of air could provide “an effective explanation of hygienic air conditions in the operating rooms” (Genet et al., 2011, p. 9). In this study, the researchers evaluated “bacterial load and antibiotic susceptibility pattern of isolates in operating rooms’ and surgical wards’ indoor air of Jimma University Specialized Hospital” (Genet et al., 2011, p. 9). The cross sectional study measured the quality of indoor air with reference to microbial quality of the ORs and surgical wards for a period of over a year.

They noted that some simple procedures could lead to low concentrations of an aerobic bacterial load in the OR and surgical wards. Some of these procedures involved reducing frequencies of foot traffic, enhancing ventilation system, and regular cleaning. In addition, healthcare facilities should enhance personnel training and develop effective intervention strategies on regular cleaning procedures for sanitary staff.

These approaches were effective on keeping the bacterial load at the best levels. Therefore, healthcare facilities that conduct various surgical operations should be well designed, ventilated and have optimal air-conditioning systems because such rooms need the highest standards of hygiene relative to other hospital environments.

In this research, the authors observed that S. aureus was the most common cause of surgical site infections. S. aureus also had the highest rate of isolation in both indoor air operating rooms and surgical wards. Therefore, contaminated indoor air in operating rooms and surgical wards is “a critical high risk factor for surgical site infections and pose risks of infections for healthcare workers” (Genet et al., 2011, p. 17).

This article demonstrated that most of surgical site infections could be prevented by effective use of infection control procedures (Sossai, Dagnino, Sanguineti, & Franchin, 2011). For example, analyzing the extent of bacterial contamination of indoor air could help in understanding the susceptibility of patients and healthcare workers. The results could be used to revise and design a new infection control guidelines to ensure that they reduce costs and rates of infections.

The authors brought a new perspective on the relationship between culture and waiting time in outpatient substance abuse treatment (OSAT) (Guerrero & Andrews, 2011). They claimed that culturally competent practice could be a significant strategy for enhancing service quality specifically for the marginalized groups. Practitioners have recognized the relevance of culturally competent service provision for outpatients, particularly with substance abuse challenges. However, conceptualizing and gauging hospital cultural competence has been a persistent source of challenge for many academics and professionals alike. The researchers noted that attempts to locate practice and attitudes, which are linguistically and culturally significance have experienced many cases of methodology drawbacks. Such drawbacks have been noted because several measures used on cultural competence evaluation normally rely on single case designs or on minimal numbers of samples for design measures. These measures are used to evaluate psychometric factors and, therefore, they can be generalized to larger groups. These factors affect outpatient waiting time and potential interventions (Mardiah & Basri, 2013).

The healthcare system caters for diverse populations that are culturally different. Hence, one must appreciate cultural variations to understand the relationship between cultural competence and outpatient waiting time.

Language or dialect, cross cultural training and promoting relations with minority groups are important practices for healthcare. Overall, they have established that language or dialect to support patients’ need is a culturally sensitive issue but necessary for improving outcomes (Guerrero & Andrews, 2011).

Guerrero and Andrew (2011) understand how a lack of cultural competence can negatively affect service delivery in hospitals and cause delays. In this regard, the authors have focused on promoting culturally sensitive practices to reduce waiting time and retention at outpatient units among minority groups. Language has been identified as a significant factor in promoting culturally sensitive practices in healthcare facilities to reduce waiting time. Most importantly, ethnic minorities should be linked with culturally sensitive healthcare providers to avoid delays.

Results from this study show that language or dialect is a culturally sensitive practice that can be used in hospitals to develop cultural competent practices for minority groups. Hospital should implement culturally sensitive practices to cater for patients who seek for care and are not natives of a given geographical location. This strategy can reduce waiting time and retention at the healthcare facility.

Nurses can attain cultural competence in the OSAT environment when they receive cross-cultural training assisted by spiritual leaders alongside community leaders based on their racial and ethnic connection with the marginalized groups. The researchers observed that fewer OSAT facilities had a considerable representation of racially and ethnically marginalized groups among their employees and leadership positions. The situation perhaps indicated challenges faced in employing and retaining racially and ethnically representative staff. In addition, the researchers also noted that it was possible to implement culturally competent processes. Managers, however, could influence the outcomes of such processes because of their culturally sensitive belief systems. Cultural sensitivity could require managers to lessen negative impacts of cultural barriers to their patients in healthcare settings. Such barriers hinder minorities from gaining access to healthcare services in outpatient departments. The results are of particular interests when evaluated within the context of past studies, which have highlighted the importance of eliminating barriers, rapid entry to interventions and the importance of retention to curb addiction severity.

Guerrero and Andrews (2011) study findings indicated that healthcare facilities cultural competence could play a significant role in reducing waiting time and enhancing patient retention in facilities that serve clients with diverse racial and ethnic backgrounds.

A surgical site infection may occur at the surgical site after a surgical procedure, which normally involves incision (Smith & Dahlen, 2013). Surgical site infection is among the most common forms of hospital-related infections. Such infections could negatively affect “wound healing, cause failures of components and lead to high costs, increased morbidity and mortality” (Smith & Dahlen, 2013, p. 242). Thus, there is a need for a clinical guideline to minimize healthcare-associated infections following surgical procedures (Baradaran-Seyed, Nedjat, Yazdizadeh, Nedjat, & Majdzadeh, 2013).

The purpose of the clinical practice guideline article was to inform healthcare workers to enhance a comprehensive strategy to control all orthopedic surgery-associated infections. The clinical practice guideline highlights a sustained use of strategies related to “preoperative surgical site preparation, intraoperative as well as postoperative care would serve to improve outcomes” (Smith & Dahlen, 2013, p. 242).

The researchers focused on collecting information related to evidence-based prevention approaches concerning surgical site infections to offer “orthopedic nurses with the required skills and knowledge to provide high quality continuous care to patients undergoing musculoskeletal system surgical procedures effectively” (Smith & Dahlen, 2013, p. 242).

The article evaluated the rigor of development of the clinical practice guideline. It was noted that the rigor of development was based on the level of evidence used and declaration of no interests among experts. The authors noted that the evidence used in the clinical practice guideline was rated to show distinction of evidence with different strengths and qualities (Smith & Dahlen, 2013). Studies must have strong rigor of development to reduce biases and enhance credibility.

The clinical practice guideline is critical on surgical site infection risks. In addition, it identifies several other patient-specific or host and procedure-related factors that could escalate risks of surgical infections after orthopedic procedures.

Nurses must also identify specific areas that require improvement and collect evidence-based measures to help in improving care.

The clinical practice guideline ensures that nurses observe quality indicators specific to infection prophylaxis, following recommendations for skin preparation, including incision and postsurgical management and observing healthcare-specific requirements.

At the same time, nurses must understand the required interventions and expected patient outcomes. The major focus of nursing interventions is to limit the multiplication of pathogens either noted or assumed by restricting getting in touch with patients (Smith & Dahlen, 2013).

Nurses must understand patient care management by identifying wound classification, preoperative care, patient education, intraoperative care, postoperative pin care in soft tissues and incision care, nursing responsibilities with prophylaxis antibacterial management and management of noncritical items exposed to intact skins of patients (Smith & Dahlen, 2013).

Meeting the clinical practice guideline recommendations requires nurse education and providing the necessary resources. Based on the nature of the facility, substantial costs may be incurred to meet the guideline recommendations. However, not all recommendations require financial investments, for instance, hand washing or scrubbing and minimizing entry in surgical rooms.

The article showed that the clinical practice guideline was intended to be implemented or applied in hospital settings by healthcare workers. Thus, nurses must strive to overcome potential barriers that could hinder the implementation of the guideline and suggested recommendations. The implementation process requires constant evaluation and improvements on outcomes.

Overall, research training in nursing at various study levels aims to enhance nursing contributions to improve health and healthcare outcomes of patients and the public. These levels prepare nursing graduates to meet the expectations and competencies to conduct nursing research and conduct various roles. The recent past, the IOM report proposed further nurse education and seamless academic progression for nurses (Institute of Medicine, 2010).

Nurses who hold bachelor degree programs acquire basic comprehension of various research processes. Graduates can use their knowledge to use research findings from nursing studies and other related fields to their clinical practice. Nurse graduates can understand evidence-based outcomes and collaborate with multidisciplinary teams to solve possible research challenges (American Association of Colleges of Nursing, 2015).

Master’s programs ensure that nurses can “assess research outcomes and create and execute evidence-based practice guidelines” (American Association of Colleges of Nursing, 2015). Nurses also acquire leadership skills at these levels to lead others. Further, they can locate possible challenges, work in teams and start studies with scientists to solve such problems.

There are also practice-oriented doctoral programs for nurses. These programs are classified as highest level of nursing practices above the basics because they prepare nurses to apply their expertise and interpret scientific knowledge for specific clinical situations to account for individuals and the public. Programs also nurture nurse leadership, collaboration, evaluate and use research instead of conducting studies.

Research-oriented doctoral programs ensure that nurse graduates can conduct further studies demonstrated through academic inquiry and independent research to discover new knowledge. Nurse graduates can work collaboratively with others when conducting studies.

Postdoctoral programs ensure that nurses can develop their research skills, formulate their research activities and work alongside formal senior mentors and investigators. Individuals’ research programs are well developed at this level of study before nurses can take any position in their areas of specialization.

References

American Association of Colleges of Nursing. (2015). Nursing Research. Web.

Baradaran-Seyed, Z., Nedjat, S., Yazdizadeh, B., Nedjat, S., & Majdzadeh, R. (2013). Barriers of Clinical Practice Guidelines Development and Implementation in Developing Countries: A Case Study in Iran. International Journal of Preventive Medicine, 4(3), 340–348.

Collins, G. S., Omar, O., Shanyinde, M., & Yu, L. M. (2013). A systematic review finds prediction models for chronic kidney disease were poorly reported and often developed using inappropriate methods. Journal of Clinical Epidemiology, 66(3), 268-77. Web.

Genet, C., Kibru, G., & Tsegaye, W. (2011). Indoor Air Bacterial Load and Antibiotic Susceptibility Pattern of Isolates in Operating Rooms and Surgical Wards at Jimma University Specialized Hospital, Southwest Ethiopia. Ethiopian Journal of Health Science, 21(1), 9–17.

Guerrero, E., & Andrews, C. M. (2011). Cultural competence in outpatient substance abuse treatment: measurement and relationship to wait time and retention. Drug and Alcohol Dependence, 119(1-2), e13-22. Web.

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Jakobsson, S., Taft, C., Östlund, U., & Ahlberg, K. (2013). Performance of the Swedish version of the Revised Piper Fatigue Scale. European Journal of Oncology Nursing, 17(6), 808–813. Web.

Kerr, K. F., Meisner, A., Thiessen-Philbrook, H., Coca, S. G., & Parikh, C. R. (2015). RiGoR: reporting guidelines to address common sources of bias in risk model development. Biomarker Research, 3(1), 2. Web.

Mardiah, F. P., & Basri, M. H. (2013). The Analysis of Appointment System to Reduce Outpatient Waiting Time at Indonesia’s Public Hospital. Human Resource Management Research, 3(1), 27-33. Web.

Mehta, R., Mavalankar, D. V., Ramani, K., Sharma, S., & Hussein, J. (2011). Infection control in delivery care units, Gujarat state, India: A needs assessment. BMC Pregnancy Childbirth, 11, 37.

Patwardhan, N., & Kelkar, U. (2011). Disinfection, sterilization and operation theater guidelines for dermatosurgical practitioners in India. Indian J Dermatol Venereol Leprol., 77(1), 83-93.

Poti, J. M., Duffey, K. J., & Popkin, B. M. (2014). The association of fast food consumption with poor dietary outcomes and obesity among children: is it the fast food or the remainder of the diet? American Journal of Clinical Nutrition, 99(1), 162-171. Web.

Sharkey, J. R., Johnson, C. M., Dean, W. R., & Horel, S. A. (2011). Focusing on fast food restaurants alone underestimates the relationship between neighborhood deprivation and exposure to fast food in a large rural area. Nutrition Journal, 10(1), 10-23.

Smith, M. A., & Dahlen, N. R. (2013). Clinical Practice Guideline Surgical Site Infection Prevention. Orthopaedic Nursing, 32(5), 242-248. Web.

Sossai, D., Dagnino, G., Sanguineti, F., & Franchin, F. (2011). Mobile laminar air flow screen for additional operating room ventilation: reduction of intraoperative bacterial contamination during total knee arthroplasty. Journal of Orthopaedics and Traumatology, 12(4), 207-11. Web.

Spichiger, E., Rieder, E., Müller-Fröhlich, C., & Kesselring, A. (2011). Fatigue in patients undergoing chemotherapy, their self-care and the role of health professionals: A qualitative study. European Journal of Oncology Nursing, 16(2012), 165-171. Web.

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NursingBird. "Risk Models in Guiding Nurses." May 3, 2022. https://nursingbird.com/risk-models-in-guiding-nurses/.