Running head: LITERATURE REVIEW 1 LITERATURE REVIEW 6 Literature Review Student’s name: Vladimir Andino University affiliation: GCU Date: 02/25/19 Literature Review Introduction Pressure ulcers, also known as bedsores or decubitus ulcers are injuries which to the skin and the underlying tissues which result from too much pressure on the skin. There are different risk factors for pressure ulcers which are very crucial in determining the type of treatment or prevention to be administered to a patient. This includes poor mobility, poor blood flow, poor nutritional status, the patient support surfaces, age, and neuropathy among others. For each of these risk factors, there are different interventions which can be used by healthcare professionals to prevent and treat pressure ulcers. The purpose of this essay is to evaluate how different research questions can be developed focusing on the risk factor of poor nutritional status. Whereas the PICOT statement outlines the interest areas of this research, this report will analyze important components of different PICOT research questions. Comparison of research questions Poor nutrition is a significant risk factor for pressure ulcers. Even though there are a few researches which support this argument, the lack of proper nutrition increases the risk of patients developing pressure ulcers (Frykberg, & Banks, 2015). Based on evidence from credible sources, there are two distinct research questions which can be developed to investigate the relationship between nutrition and prevalence of pressure ulcers. The first question is whether providing necessary nutritional requirements to patients reduces their risk of developing pressure ulcers. The second question is whether providing additional nutritional supplementation to patients with pressure ulcers improve healing. The first question relates directly to the PICOT statement and focuses on establishing whether the provision of certain nutrients to patients will prevent the incidence of the condition. As such this research would only be viable for patients who don’t have pressure ulcers. The second question, on the other hand, investigates whether enhancing the nutritional intake of patients helps in treating pressure ulcers. According to the National Institute for Health and Care Excellence (2014), there are different nutrients which are known to enhance pressure ulcer repair through collagen formation and development of connective tissue. These nutrients include vitamin C, protein, and zinc. This research is viable for patients who already have pressure ulcers. Even though each of these research questions aims at investigating the impact on nutrition on the prevalence of the condition, the second research question would be more effective. This is because in the first question other risk factors may have a huge impact on the research. Comparison of sample populations The population at high risk of developing pre.

1. Running head: LITERATURE REVIEW
1
LITERATURE REVIEW
6
Literature Review
Student’s name: Vladimir Andino
University affiliation: GCU
Date: 02/25/19
Literature Review
Introduction
Pressure ulcers, also known as bedsores or decubitus ulcers are
injuries which to the skin and the underlying tissues which
result from too much pressure on the skin. There are different
risk factors for pressure ulcers which are very crucial in
determining the type of treatment or prevention to be
administered to a patient. This includes poor mobility, poor
blood flow, poor nutritional status, the patient support surfaces,
age, and neuropathy among others. For each of these risk

2. factors, there are different interventions which can be used by
healthcare professionals to prevent and treat pressure ulcers.
The purpose of this essay is to evaluate how different research
questions can be developed focusing on the risk factor of poor
nutritional status. Whereas the PICOT statement outlines the
interest areas of this research, this report will analyze important
components of different PICOT research questions.
Comparison of research questions
Poor nutrition is a significant risk factor for pressure ulcers.
Even though there are a few researches which support this
argument, the lack of proper nutrition increases the risk of
patients developing pressure ulcers (Frykberg, & Banks, 2015).
Based on evidence from credible sources, there are two distinct
research questions which can be developed to investigate the
relationship between nutrition and prevalence of pressure
ulcers. The first question is whether providing necessary
nutritional requirements to patients reduces their risk of
developing pressure ulcers. The second question is whether
providing additional nutritional supplementation to patients
with pressure ulcers improve healing.
The first question relates directly to the PICOT statement and
focuses on establishing whether the provision of certain
nutrients to patients will prevent the incidence of the condition.
As such this research would only be viable for patients who
don’t have pressure ulcers. The second question, on the other
hand, investigates whether enhancing the nutritional intake of
patients helps in treating pressure ulcers. According to the
National Institute for Health and Care Excellence (2014), there
are different nutrients which are known to enhance pressure
ulcer repair through collagen formation and development of
connective tissue. These nutrients include vitamin C, protein,
and zinc. This research is viable for patients who already have
pressure ulcers. Even though each of these research questions

3. aims at investigating the impact on nutrition on the prevalence
of the condition, the second research question would be more
effective. This is because in the first question other risk factors
may have a huge impact on the research.
Comparison of sample populations
The population at high risk of developing pressure ulcers is
adults who suffer from conditions such as spinal cord injury,
stroke, or old age which makes them immobile. For each of the
research, it would be important to identify a target population
which shares a close similarity. This is because the incidence of
pressure ulcers is dependent on the environment of the patient.
For example, it may be difficult to identify early signs of
pressure ulcers for a patient with a skin condition which affects
the normal appearance of the skin. For the first research
question, the sample population will only include patients who
have not contracted pressure but are at risk of contracting the
disease due to their health conditions. For example, patients
who are admitted for bed rest for a long time. For the second
research question, it will be important to sample patients who
are initially under the same conditions and environments. For
example, the research will primarily focus on patients with
spinal injury in a particular from a particular nursing home.
This means that each of the patients receives similar care
service and is given the same foods or foods with similar
nutritional values. The control group will then be introduced to
foods with additional nutrients which are known to reduce the
effect of pressure ulcers.
Comparison of the limitation of the study
For the first research question, the main limitation of the study
is that it may be difficult to evaluate the effects of other risk
factors on the outcomes of the research. For example, it may be
challenging to determine whether a patient developed pressure

4. ulcers due to poor nutrition or factors such as age, pain which
may prevent patients from moving, or the condition of the
supporting surface. The limitation of the second research,
however, may be majorly science-based. For example, pressure
ulcers are caused by both aerobic and anaerobic bacteria (Dana,
& Bauman, 2015). As such, different nutritional requirements
may be needed in order to destroy them. For both types of
research, the major limitation is that the use of a small sample
population may not represent all the patients and as such, the
research can only be relevant to preventing certain cases of the
disease.
Conclusion
Both presented research questions present valid approaches for
investigating the relevance of nutrition in preventing and
treating pressure ulcers. From each research study, the expected
outcome will include a list of essential nutrients which are
necessary for the prevention of the condition. Nonetheless,
different patients have different health and nutritional needs
which is related to their age, general body metabolism, or other
factors. This may cause some irregularities of the results. As
such, there is a need to include intensive scientific and clinical
interventions during the project to ensure that causes of
irregularities are identified and justified. This project can be
used to improve further research to determine the specific
nutritional needs which are needed to address the different
kinds of pressure ulcers; either caused by aerobic or anaerobic
bacteria.
References
Ali N. Dana, & William A. Bauman, (2015). Bacteriology of
pressure ulcers in individuals with spinal cord injury: What we
know and what we should know. J Spinal Cord Medicine; 38(2):
147–160. doi: 10.1179/2045772314Y.0000000234.
Frykberg, R. G., & Banks, J. (2015). Challenges in the

5. treatment of chronic wounds. Advances in wound care, 4(9),
560-582.
National Institute for Health and Care Excellence (UK), (2014).
The Prevention and Management of Pressure Ulcers in Primary
and Secondary Care. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK333125/
Econ 1020
Winter 2019
Assignment 4
Due date: March 15
Please do not simply indicate results, but show the formulas that
you use
Exercise 1
You are given the following data concerning a certain economy:
1) Consumption function: C = 80 + 0.6 Y
2) Investment function: I = 200
3) AE ( C + I
4) AE ( Y
(a) Graph equations 3) and 4), solve for equilibrium income (or
output), and show it on your graph.
(b) What is the relationship between planned investment and
actual investment in correspondence of the equilibrium level of
income (or output)? Explain.
(c) Suppose equation 2) is changed to 2’) I = 150. What is the
new equilibrium level of income (or output)?
(d) Represent the effect of (c) on the graph you obtained in (a).

6. (e) Why is the decrease in output greater than the change in
investment? Explain the economic process behind this result.
Exercise 2
You are given the following data concerning a certain country:
1) Consumption function: C = 100 + 0.7 (Y-T)
2) Investment function: I = 50
3) G =70
4) T =20
5) AE ( C + I + G
6) Y ( AE
(a) What is the equilibrium level of output (or income)?
(b) Graph the AE and Y curves and show the equilibrium level
of income on your graph.
(c) What is the effect on the equilibrium level of output (or
income) of an increase of government spending by 30 (which
means G’=100)? Calculate your answer numerically and show it
on it on the graph you drew in (b).
(d) How does the surplus/deficit of the government changes
after an increase in government spending by 30?
(e) What is the effect on the equilibrium level of income (or
output) of an increase in taxes by 20 (which means T’=40)?
Exercise 3
Given the following model of an economy:
C = 6,000 + 0.75 (Y-T)
I = 11,000
G = 20,000

7. T = 16, 000
a) Calculate the equilibrium level of output (or income);
Assume estimations calculate that the full-employment level of
output is $150,000:
b) If the government wanted to use G to achieve the full
employment level of output, by how much should G
increase/decrease?
c) If the government wanted to use T to achieve the full
employment level of output, by how much should T
increase/decrease?
d) Why G and T change by a different amount to achieve the
same goal of moving the economy to the full-employment level
of output of $150,000?
PAGE
1
Running head: LITERATURE EVALUATION TABLE
LITERATURE EVALUATION TABLE
5
Literature Evaluation Table
Name: Vladimir Andino
Institution: GCU
Date: 2/10/19
Criteria
Article 1
Article 2

8. Article 3
Article 4
Author, Journal (Peer-Reviewed), and
Permalink or Working Link to Access Article
Haegdorens et, al. The introduction of a rapid response system
in acute hospitals: a pragmatic stepped wedge cluster
randomized controlled trial. Resuscitation
McIlvennan et, al. Hospitals readmissions reduction program
131(20), 1796-1803.
Santamaria et, al. (2018) Increasing the Number of Medical
Emergency Calls Does Not Improve Hospital Mortality. Critical
care medicine, 46(7), 1063-1069.
Lone, Lee, & Walsh, (2019). Long-Term Mortality and Hospital
Resource Use in ICU Patients With Alcohol-Related Liver
Disease. Critical care medicine, 47(1), 23-32
Article Title and Year Published
April 18, 2018
2015 May 19
2018 July
Published May 2019
Research Questions (Qualitative)/Hypothesis (Quantitative), and
Purposes/Aim of Study
Investigate the implications of an RRS on the incidence of
unexpected death or unplanned ICU admission
Examine whether hospitals readmissions are related with
unfavorable patients outcomes and financial costs
The objective is set to examine the correlation between
emergency calling rates and adjusted in-hospital death
The study sought to examine the correlation between MET and

9. hospitals mortality
Design (Type of Quantitative, or Type of Qualitative)
Quantitative
Quantitative
Quantitative
Quantitative
Setting/Sample
N= 14
Setting = 14 Belgian acute hospitals
2 = medical wards
2 = surgical wards
Based on data 2008-2011 of penalized hospitals for excessive
readmissions.
Tertiary, metropolitan as well as regional hospitals in Australia
N = 441, 029
N =12
The study randomized 23 hospitals in Australia
Methods: Intervention/Instruments
Standardized observation and communication
Pre-experimental
Pre-experimental
Evidence implemented
Analysis

10. According to Haegdorens et, al. (2018), although the MET
system increases emergency team calling, it does not entirely
affect the incidence of unexpected deaths.
None
None
Study as a global challenge needs to be addressed in all aspects.
Key Findings
Introduction of the EMT increases the overall calling incidence
for an emergency team
The study found that increased emergency rates were not
connected with reduced- in hospital deaths.
The study found that the introduction of the MET increased the
overall calling for an emergency team
Recommendations
None
Due to improvement in health IT, this should boost
incorporation of greater clinical details
None
The study enhances proactive roles
Explanation of How the Article Supports EBP/Capstone Project
This study provides evidence that could be used to conduct
future research
The study provides essential findings to health practitioners
and society at large
The study advices proactive measures to prevent childhood
obesity
Criteria

11. Article 5
Article 6
Article 7
Article 8
Author, Journal (Peer-Reviewed), and
Permalink or Working Link to Access Article
Reilly, et al, (2018). Early life risk factors for obesity in
childhood: cohort study. Bmj, 330(7504), 1357.
Strugnell et al. (2018). Active (Opt-In) Consent Underestimates
Mean BMI-z and the Prevalence of Overweight and Obesity
Compared to Passive (Opt-Out) Consent. Evidence from the
Healthy Together Victoria and Childhood Obesity
Study. International journal of environmental research and
public health, 15(4), 747.
Wang et, al. (2018). Childhood obesity prevention through a
community-based cluster randomized controlled physical
activity intervention among schools in china: the health legacy
project of the 2nd world summer youth olympic Games (YOG-
Obesity study). International Journal of Obesity, 42(4), 625.
Hillier-Brown et al. (2014). A systematic review of the
effectiveness of individual, community and societal level
interventions at reducing socioeconomic inequalities in obesity
amongst children. BMC public health, 14(1), 834.
Article Title and Year Published
Published 09 JUNE 2018
Published 05 October 2017
Published October 2017
Published 11th August 2014
Research Questions (Qualitative)/Hypothesis (Quantitative), and
Purposes/Aim of Study

12. The study seeks to identify risk factors for obesity in children.
The study tracks population trends in childhood obesity
The study investigates childhood obesity and hot it can be
prevented by introducing physical activities in schools
The study aimed to examine health policy challenges in terms of
addressing social-economic equalities
Design (Type of Quantitative, or Type of Qualitative)
Cohort study
Quantitative
Experimental
Pre-experimental
Setting/Sample
8234 children aged 7 years.
N= 47 schools
N= 2557 students participated in the study
The study is based on clustered randomized intervention among
schools in Asia, particularly China
The study located 23 studies that provided the best convincing
international evidence
Methods: Intervention/Instruments
Avon longitudinal study of parents and children
Cross-sectional study that examined changes in BMI-z and risk
associated.
Clustered randomized intervention study
A systematic review

13. Analysis
Obesity in early life is associated with various factors.
The study presented high prevalence of obesity or overweight
Promoting community based intervention was effective in
preventing obesity
According to this study, tackling obesity is a major challenge
worldwide hence the need to address factors that could be
promoting this phenomenon
Key Findings
Eight factors are associated with an higher risk of obesity in
childhood
High prevalence of obesity.
Obesity can be overcome through community interventions
activities i.e. physical activities
The study suggests no convincing evidence to explain how
inequalities can be associated with obesity
Recommendations
None
The study recommends on the best approaches to fight obesity
in the society
The study emphasis physical activities in learning institutions to
prevent childhood obesity
None
Explanation of How the Article Supports EBP/Capstone
The study supports EBP in the sense that it seeks to understand
a global epidemic.
The work was supported by global recognized bodies. The study
aids in understanding a global phenomenon

14. The study provides lessons essential in controlling childhood
obesity epidemic
This study guides future obesity researches
References
Haegdorens, F., Van Bogaert, P., Roelant, E., De Meester, K.,
Misselyn, M., Wouters, K., & Monsieurs, K. G. (2018). The
introduction of a rapid response system in acute hospitals: a
pragmatic stepped wedge cluster randomised controlled
trial. Resuscitation.
Hillier-Brown, F. C., Bambra, C. L., Cairns, J. M., Kasim, A.,
Moore, H. J., & Summerbell, C. D. (2014). A systematic review
of the effectiveness of individual, community and societal level
interventions at reducing socioeconomic inequalities in obesity
amongst children. BMC public health, 14(1), 834.
Lone, N. I., Lee, R., & Walsh, T. S. (2019). Long-Term
Mortality and Hospital Resource Use in ICU Patients With
Alcohol-Related Liver Disease. Critical care medicine, 47(1),
23-32.
McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015).
Hospital readmissions reduction program. Circulation, 131(20),
1796-1803.
Reilly, J. J., Armstrong, J., Dorosty, A. R., Emmett, P. M.,
Ness, A., Rogers, I., ... & Sherriff, A. (2005). Early life risk
factors for obesity in childhood: cohort study. Bmj, 330(7504),
1357.
Santamaria, J., Moran, J., & Reid, D. (2018). Increasing the
Number of Medical Emergency Calls Does Not Improve
Hospital Mortality. Critical care medicine, 46(7), 1063-1069.
Strugnell, C., Orellana, L., Hayward, J., Millar, L., Swinburn,
B., & Allender, S. (2018). Active (Opt-In) Consent

15. Underestimates Mean BMI-z and the Prevalence of Overweight
and Obesity Compared to Passive (Opt-Out) Consent. Evidence
from the Healthy Together Victoria and Childhood Obesity
Study. International journal of environmental research and
public health, 15(4), 747.
Wang, Z., Xu, F., Ye, Q., Tse, L. A., Xue, H., Tan, Z., ... &
Wang, Y. (2018). Childhood obesity prevention through a
community-based cluster randomized controlled physical
activity intervention among schools in china: the health legacy
project of the 2nd world summer youth olympic Games (YOG-
Obesity study). International Journal of Obesity, 42(4), 625.
Running Head: PRESSURE ULCERS2
Title: Pressure Ulcers
Student Name: Vladimir Andino
Institution: GCU
Date: 01/27/2019

16. High cases of pressure ulcers are recorded with patients who
have been admitted to hospitals. It is a skin and tissue which is
highly identified with people who are bed-bound or those
people who have little or no mobility. Therefore, it is a
condition that I have seen with most patients who have been
admitted to the hospital. This condition is therefore important
and needs to be addressed in order to come up with solutions on
how to deal with it.
Pressure ulcers can be described as a condition where the skin
and the underlying tissues are injured due to applied pressure on
that point for a very long time. It is also referred to as bed sore
(Chauhan, 2012). It affects areas which are bony such as elbows
and knees. The major symptom of pressure ulcers are deep
wounds at the affected area. In severe cases, the wounds may
reach the bones and this may cause other complications on the
patient if not treated. It mainly affects older people and patients
who have been confined in their hospital bed (Jaul, 2010).
However, it is a manageable condition especially if treated at an
early stage.
The impact of Pressure ulcers on the working environment is
that it has led to the incorporation of more specialized care on
the patients. The nurses have to change the patient’s position
frequently. This further implies that nurses have to be more
careful and offer additional help to the patients. However, it
impacts the patient negatively. Pressure ulcers lead to other
complications that in turn lead to death. It is a condition that
also comes with a lot of pain, discomfort and more days in
hospitals (Professor, 2009).
The significance of this topic is that it has brought awareness of
Pressure ulcers. People are now aware of this condition and are

17. taking measures to prevent it (R, 2008). One implication on
nursing is that nursing patterns have to change. This is because
when dealing with pressure ulcers, special attention is given to
patients. Also, the nurses have to take initiative to educate
patients on ways to deal with Pressure ulcers. With Pressure
ulcers awareness, patients will comply more and adhere to the
measures of managing pressure ulcers. Therefore the main
implication on nursing is creating awareness to patients and
guiding them on how to deal with pressure ulcers.
As a solution to this problem, nurses should be engaged in a
health program dealing with Pressure ulcers. Under these
programs, the nurses will be equipped with skills and
knowledge on how to deal with patients with pressure ulcers
(Irene M.JankowskiR.N, 2011). They will also learn how to
detect pressure ulcers at early stages. Another solution to this
problem is the availability of equipment for measuring pressure
on the vulnerable areas. This will help in the detection of
pressure ulcers before they become severe (Jill Cox, 2011).
Finally, a health program for patients raising the awareness of
Pressure ulcers is very important. This is because they will have
the basic information on how to prevent, detect and deal with
pressure ulcers (Levine, 2012)
In conclusion, Pressure ulcers have been on the rise and they
have to be dealt with. Having identified who it affects, how it is
treated and managed, it is up to the nurse, patients, and the
public to apply actions which will lead to a reduction of
Pressure ulcers cases. In doing this, we will overcome this
problem of Pressure Ulcers.
References
Chauhan, K. A. (2012). Pressure ulcers: Back to the basics.
Indian Journal of plastic surgery .
Irene M.JankowskiR.N, D. M. (2011). Identifying Gaps,
Barriers, and

18. Solution
s in Implementing Pressure Ulcer Prevention Programs. The
Joint Commission Journal on Quality and Patient Safety .
Jaul, E. (2010). Assessment and Management of Pressure Ulcers
in the Elderly. Drugs & Aging .
Jill Cox, R. P. (2011). Predictors of Pressure Ulcers in Adult
Critical Care Patients. The Standard for critical care and
progressive care nursing education .
Levine, J. M. (2012). Pressure Ulcer Knowledge in Medical
Residents: An Opportunity for Improvement. Skin and Wound
care .
MD, C. K. (n.d.). Human skin wounds: A major and snowballing
threat to public health and the economy. The International
journal of tissue repair and regeneration .
Professor, C. G. (2009). Impact of Pressure Ulcers on Quality of
Life in Older Patients: A Systematic Review. Journal of the
American Geriatrics Society .
R, F. (2008). Decreasing the incidence of heel pressure ulcers in
long-term care by increasing awareness: results of a 1-year
program. Europe PMC .

19. Running Head: PICOT STATEMENT PAPER
1
PICOT STATEMENT PAPER
5
Pressure Ulcers Prevention in Nursing Facilities
Student’s name: Vladimir Andino
Institution Affiliation: GCU
Date: 2/3/19
Picot Statement paper on Pressure ulcers prevention in nursing
facilities
Pressure ulcers or bedsores are injuries that occur on the skin
surface when it is exposed to too much pressure. These injuries
can occur to any individual, but the most affected population is
sick people who are confined in bed, or people who sit in a
wheelchair or chair for long periods. The major risk factors that
predispose individuals to this ailment include immobility,
health problems which limit blood flow, poor nutrition, and loss
of sensation due to impairment of sensory perception. This
study focuses on developing a PICOT statement that will aid in

20. limiting the incidences of pressure ulcers in nursing facilities.
Picot statement
P (Problem)
Pressure Ulcers in nursing facilities
I (Intervention)
Proper nutrition
C (Comparison)
Patient population not currently receiving the intervention
O (Outcome)
Less pressure ulcers in nursing facilities
T (Timeframe)
Period before and after intervention
Problem (Pressure ulcers in nursing facilities)
Patients in nursing facilities are at a higher risk of contracting
pressure ulcers because their poor health may cause them to
lack the energy to adjust their bed elevations regularly. This
population also experience mobility problems, and they may
also fail to detect the injuries in good time due to lack of
sensory perceptions (Stechmiller, 2010). Too much pain because
of other ailments may also cause them to underestimate the
effects of pressure ulcers. Pressure ulcers is thus a significant
healthcare problem in nursing facilities that need to be checked.

21. Intervention (Proper nutrition)
Though pressure ulcers are popularly known to be caused by
immobility problems, poor nutrition also plays a substantial role
in influencing the disease. Failing to include sufficient
vitamins, minerals, calories, proteins, and fluids in the patients’
diet in order to maintain healthy skin predisposes the patients to
more risk of contracting pressure ulcers (Shahin et al., 2010).
This study will thus involve provision of patients in nursing
facility A with all the necessary food materials for maintaining
a healthy skin. A change in diet will thus have to occur, and
nurses in the nursing facility will oversee the implementation of
the intervention. Nurses in the care facility will however, be
enlightened on the specific nutritional foods that should be
given to the patients. Other factors that predispose patients to
pressure ulcers will remain unaltered.
Comparison (Patient population not currently receiving the
intervention)
The results of the intervention will be compared to a nursing
facility B that will not have adopted the intervention. Nursing
facility B will also be monitored throughout the experiment

22. though no intervention will be executed.
Outcome (Less patient ulcers in nursing care facilities)
The results of the experiment show that the instances of
pressure ulcers in the nursing facility reduced significantly
since the time the intervention was implemented. The results
thus implied that poor nutrition plays a vital role in causing
pressure ulcers, and thus implementing proper nutrition can help
significantly in reducing the effects. When the results were
compared with those of nursing facility B, which had not
received the intervention, the facility was found to have
increased the instances of pressure ulcers.
Timeframe (Period before and after the intervention)
The intervention program in this study took a period of three
months, and it involved patients in nursing facilities who had
significant immobility challenges. Proper nutrition was given
preference because it would help in maintaining a healthy skin,
and hence the skin would be more resilient to pressure ulcers
(Stechmiller, 2010). Before implementation of the intervention
program records about pressure ulcers on the patient population
were taken so that they could be compared with the end results
of the intervention.

23. References
Shahin, E. S., Meijers, J. M. M., Schols, J. M. G. A., Tannen,
A., Halfens, R. J. G., & Dassen, T. (2010). The relationship
between malnutrition parameters and pressure ulcers in
hospitals and nursing homes. Nutrition, 26(9), 886-889.
Stechmiller, J. K. (2010). Understanding the role of nutrition
and wound healing. Nutrition in clinical practice, 25(1), 61-68.