Keywords (314)

The Annual Publication of the American Psychiatric Nurses Association 25th Annual Conference Abstracts

The Annual Publication of the American Psychiatric Nurses Association 25th Annual Conference Abstracts,10.1177/1078390311431052,Journal of The America

The Annual Publication of the American Psychiatric Nurses Association 25th Annual Conference Abstracts  
BibTex | RIS | RefWorks Download
Janet Somlyay, Jolie Gordon-Browar, Lynne Ashbeck, Kris Lambert, Susan Boorin, Renee Latimer, Rose Clute, Sharon Valente, Angela Albright, Elizabeth Winokur, Joan Masters, Beverly Hatch
Educating undergraduate nursing students in psychiatric nursing can be challenging. Engaging and connecting with nursing students using various teaching strategies based on Howard Gardner’s Multiple Intelligences Theory will be described. Nursing students have the opportunity to learn about mental illness and mental health in a creative class and then transfer this new knowledge to any health care setting. Individual student and group activities in the classroom include mental health promotion group posters, Hearing Voices™, homework using crayons, and use of therapy balls and therapy communication cards. Out of the classroom assignments include a creative psychiatric media project and, interviewing nonnursing helping professionals on crisis management engages the nursing student on a multiple intelligences level. Popular learning activities include a fun therapy day where students are introduced to multiple (positive and negative) therapeutic modalities as well as mock party where students role-play individuals with personality disorders. Undergraduate nursing students are more willing to learn psychiatric nursing knowledge and skills in a creative classroom environment using spatial, interpersonal, body-kinesthetic, interpersonal, and intrapersonal intelligences. Learn how to infuse one or more of these teaching strategies into your nursing classroom.This presentation will outline the successes and challenges faced by a multicounty task force in the Central Valley of California formed to address a health care crisis born from the closure of the county mental health crisis unit. This “5150 Task Force” is composed of local law enforcement, local hospitals, psychiatric nurse leaders, patient advocacy groups, emergency response services, and County Department of Behavioral Health staff. The task force, led by the leadership of the local chapter of the Hospital Council (part of the California Hospital Association), meets monthly, with ad hoc meetings more frequently, to analyze the impact, critique the proposed mental health delivery plan, and to devise individual and group responses to the anticipated changes. More than a year postclosure, we are still working on improving the care available to consumers in crisis, as well as improving the process for the agencies involved. This presentation will review the work done by the task force including the improvements recommended, the outcome of the changes, and the work yet to be done.There has been a resurgence of interest in adopting a more personalized and subjective approach to caring for individuals with mental illness; the recovery model. Its controversial nature is being challenged by those initially doubtful of its practicality and usefulness: physicians and nurses. It is not enough to announce the decision to adopt recovery as the care model of choice. Policy changes, care initiatives, programmatic modifications, and staff education must follow. How can administrators and educators achieve buy-in from those in direct patient care roles? How is the philosophy of recovery translated into day-to-day interaction with patients, families, and colleagues? How do we “make it real” for those in our care? Using the principles of recovery, an interactive, educational program is offered using the process of reflective practice to deconstruct the recovery model—looking specifically at the role language plays in understanding the recovery model in mental health care. In using reflective practice techniques, participants are prompted to internally investigate, analyze, and critically evaluate their current belief system and daily practice habits by exploring the language they use to communicate. Recovery-focused language is introduced as a method of promoting patient-centered/recovery-oriented care.In 2006, risperidone was approved for children with autism accompanied by serious behavioral problems. Although risperidone is associated with significant improvement in symptoms, weight gain and potential for cardiometabolic changes have emerged as important clinical concerns. The purpose of this study is to examine a range of cardiometabolic indices in children with autism treated with risperidone. Study subjects are 124 children (4-13 years old) diagnosed with autism and serious behavioral problems who participated in a trial by the Research Units on Pediatric Psychopharmacology (RUPP) Autism Network comparing risperidone with risperidone plus parent training. Data are available on appetite, waist/hip ratio, blood pressures/pulse/temp, and weight for 6 months and fasting glucose, liver enzymes, triglycerides, insulin, adiponectin, and leptin after 4 months. No previous study has reported on this range of cardiometabolic indices in children with autism and treated with risperidone. Analysis shows excessive weight gain, significant increases in BMI, increased appetite, and a broad worsening in cardiometabolic status. Clinicians need to understand lipocentric cardiometabolic side effects of risperidone in children, the relationship between lipocentric pathophysiologic changes and office-based screening measures, and pediatric monitoring recommendations to guide clinical practice.Persons with serious mental illness have a 1.5 to 2.0 times higher risk of diabetes and obesity than the general population, even after controlling for medications. Being overweight contributes to the constellation of risk factors known as metabolic syndrome. Persons with mental illness often lack health insurance, delay seeking care, and are less likely to receive lifestyle behavior counseling and medication for conditions such as hyperlipidemia and cardiovascular disease. Calorie-dense, nutrient-poor diets, and lack of exercise are other factors that drive weight gain in the seriously mentally ill population. This feasibility study seeks to replicate elements of successful metabolic syndrome risk reduction programs and adapt these elements to a population at increased risk due to mental illness and ethnicity. This study will build on the infrastructure of a partial hospitalization program, by incorporating three additional components: (a) a locally developed curriculum shown to be successful in improving risk factors for metabolic syndrome in a worksite study targeting Asian Americans and Pacific Islanders (SugarWatch), (b) structured physical activity, and (c) healthy food demonstrations during group lunch. Outcome measures include trends in pre- and posttests of knowledge, physiological measures, nutritional intake, and level of physical activity plus feasibility measures.Suicide is the 11th top cause of U.S. death with 32,000 suicides/year, with increases among military personnel/veterans aged 18 to 29 years, who have twice the risk of civilians. Screening tools do not detect those at highest risk. The purpose is to describe data about military/veteran suicides, risk factors, and prevention. Harm reduction model is used in the study. Retrospective chart review indicates that risk factors include posttraumatic stress disorder (PTSD) or depression, and traumatic brain injury during deployment, number of combat trauma exposures, poor help seeking, inadequate treatment, Dear John/Jane letter, and feeling like a burden. Hanging is the most common method for inpatients, although overdose and cutting prevail on medical units, domiciliaries, and nursing home care units. Doors, especially interior doors, are the most common anchor points. In all, 25% of suicides occur on nonpsychiatric units. Common locations of suicide include bathroom, hallways, bedrooms, closet, and showers. Precautions include monitoring environment of care and removing dangerous objects. Nursing plays a critical role in developing rapport, assessment, monitoring risk, and interventions. Research on barriers to nursing management of risk is discussed. Common errors in assessment are examined.Mentally ill persons suffer chronic medical illnesses more often than those in the general population and thus, may be likely to require hospital care. When hospitalized on nonpsychiatric units, these patients may exhibit behaviors that confound nonpsychiatric nurses. This research described acute care nurse competencies in managing these patients. This is a correlational study describing nurse competencies related to caring for patients who have behavioral health issues and are cared for in nonpsychiatric settings. Sample consisted of direct care provider RNs from three hospitals. The measure is a 31-item investigator-developed instrument measuring nurse competencies related to assessment, care, and resources for patients cared for in nonpsychiatric units; developed following literature review, evaluated by nonpsychiatric staff nurses; and administered through secure online delivery. The RN staff participation was invited via hospital Intranet and work e-mail. Data analysis included descriptive statistics, chi-square, and analysis of variance (ANOVA) models. A total of 844 nurses, most female and without psychiatric experience. Top responses indicated that nurses can assess for suicide risk and recognize symptoms of alcohol/drug withdrawal, but have difficulty intervening with hallucinations and conflict. Responses about resource availability varied among organizations. Responses of our survey may differ in hospitals with different resources. Information from this survey can serve as a needs assessment for clinical education.Psychiatric nursing can be an intimidating experience for undergraduates as well as for inexperienced staff and graduate students. One way of promoting empathy, clinical knowledge, and commonality of experience is to have students or staff read a memoir written by a psychiatric nurse or psychiatrist. Although memoirs are highly personal, reading about how other people thought through difficult situations and implemented a course of action can help students and staff improve their own clinical reasoning. A search for psychiatric practitioner memoirs on the CINAHL and Medline databases produced no hits but searches of the Google and Amazon websites found an additional 12 English-language memoirs written by psychiatric nurses and psychiatrists in addition to 2 I already use. All 14 were reviewed for clinical accuracy, clinical relevancy, positive role-modeling, patient advocacy, promotion of a positive image of nursing, and enjoyment. Reactions of students and nurses new to psychiatry to the books Psychward by Stephen B. Seager and Of Spirits and Madness: An American Psychiatrist in Africa by Paul R. Linde have been highly positive. Recommendations are given for using selected memoirs as a learning activity in the university or staff development setting.Inpatient psychiatric nurses assess patients and make care decisions based on frequently changing needs. Among these is the requirement for patient safety, specifically for those who are acutely suicidal, have varying behavioral disturbances, represent a threat to others, or are physically compromised. Patients, families, physicians, and nurses often believe that patients will remain safe by providing them with a sitter. In this model, a caregiver sits at the bedside or remains within arms’ length of the patient, and watches, assists, and attempts to ensure patient safety by preventing harm to self or others, or preventing falls. With escalating health care costs, use of sitters is an increasing financial burden to hospitals. Despite its routine and extensive use, there is no clear-cut evidence that continuous one-to-one observation is the only effective means of providing safe care. By exploring alternative interventions, there is potential for maintaining quality of care while reducing cost. Using an interdisciplinary team, this inpatient behavioral health unit developed alternatives, including policy revision, assessment and documentation protocols, and guides outlining least restrictive measures. Year-to-date sitter hours have decreased by 50% with no increase in patient injuries or violence against staff or other patients. Changes are easily replicated by other institutions.This presentation is intended to identify significant factors in development of and recovery from co-occurring disorders of Kleinfelter’s syndrome, personality disorder, major depression, severe and persistent drug and alcohol abuse, and suicide-intended life-threatening self-injury. As providers have become more aware of the complexity of issues faced by many of the clients they serve, the path to recovery has become more difficult to chart. Individual issues of chronic medical diseases, major mental disorders, personality disorders, and drug, alcohol, and inhalant chronic use can be overwhelming both for the client and his or her service providers. The capacity and competency of service providers to identify multiple co-occurring disorders and simultaneously chart paths to recovery are essential for many clients. Providing these services in a coordinated nonconflicting delivery calls for the best that clinicians and medical providers have to offer. Identifying when various treatments are in conflict and resolving this dilemma requires new levels of communication, cooperation, and co-effort by both clients and service providers. The reward for successfully negotiating these new demands is recovery for those served and enhanced skills for service providers.Adolescents with serious emotional disturbances, including disruptive disorders (i.e., attention deficit/hyperactivity disorder, oppositional, and conduct disorders) are four times more likely than the general population of adolescents to drop out of school, use drugs, or be arrested. There is an urgent need to identify strengths-based factors associated with improvement in adolescent behavioral and social functioning to help them achieve their full potential. The purpose of this study was to determine whether change in adolescent personal strengths and family functioning predict change in behavioral and social functioning for adolescents with disruptive disorders, and if findings vary by race. Guided by McCubbin and Patterson’s Double ABCX Model, secondary analyses were conducted using longitudinal data from 179 adolescents (aged 12-17 years) with disruptive disorders and their caregivers. Data were collected via interviews with caregivers using four measures. Multivariate multiple regressions were used for analysis. Increase in adolescent personal strengths was associated with improvement in behavioral and social functioning. Family functioning was not a significant predictor. There was no effect of race. Findings provide evidence for psychiatric mental health nurses to focus on enhancing adolescent personal strengths to improve behavioral and social functioning in adolescents with disruptive disorders.Obesity, metabolic syndrome (MS), and cardiovascular disease are major public health problems. Studies suggest that some psychiatric medications are associated with weight gain, glucose dysregulation, and diabetes. Our study examines risk factors of MS on inpatient psychiatric units and the incidence of medical referrals on discharge. The study design involved a prospective chart review of 125 patients admitted to psychotic disorder units. Information collected included demographics, specific risk factors for MS, other health risk factors (e.g., smoking substance use), leisure activity, medications, diagnoses, and information regarding primary care providers (PCPs) and referrals. Using the Adult Treatment Panel III definition of risk factors for MS, comparison analysis was made for two groups, those with two or more risk factors and those with less than two risk factors. The differences in the groups were statistically significant for age, waist circumference, systolic blood pressure, body mass index, high-density lipoprotein, triglycerides, and fasting glucose levels. Few patients were referred to their PCP for follow-up care. This study has implications for improving assessment of psychiatric patients at risk for MS, for designing lifestyle modification and interventions to mitigate these risks, and to improve integration of psychiatric and primary care.Military families face unique challenges related to the military lifestyle, which often result in feelings of loss. Grief related to loss, is an integral, often unrecognized component of military family life. Unrecognized and unmitigated grief has the propensity to amplify physical, psychological, and psychosocial challenges that present in the clinical setting. Early recognition, acknowledgment, and the normalizing of grief as part of the healing process will enhance the quality of care provided for the military family member. The military community today is composed of active duty, reserve, civil service, and contract employees. Many who serve will leave active service and return to civilian communities, essentially amputated from the tight-knit military culture through which they were able to share the uniqueness of the life, support, and camaraderie. Frequently, health care provided to military families is by nonmilitary providers. Few civilian providers know enough about the military way of life to understand the potential for loss. By understanding the essentials of military life, recognizing loss associated with it, and knowing how to manage that loss will facilitate care and reduce the potential for more serious mental illness, increase the umbrella of support, and reduce the potential for self-imposed catastrophic events.Patients with a borderline personality disorder (BPD) diagnosis with self-harm issues may be “stigmatized” as resistant to treatment which may affect nurses’ attitudes toward their care, and the nurse–patient interpersonal relationship. Determining the attitudes of psychiatric nurses toward patients with BPD with self-harm issues is the first step toward enhancing positive outcomes for patients with BPD. The aim of this study was to determine the attitudes of psychiatric nurses toward patients with a BPD diagnosis and self-harm issues. Peplau’s interpersonal theory of therapeutic relationships provides the theoretical framework for this study. This descriptive correlational study examined the attitudes of a sample of psychiatric nurses working on the adult behavioral health units of three psychiatric hospitals in Pennsylvania, using the Adapted Attitude Towards Deliberate Self-Harm Questionnaire. The Statistical Package for Social Services Version 17.0 software was used for data analysis in this study. Years of service and need for further education were significantly related to psychiatric nurses’ attitudes toward BPD patients experiencing self-harm. Psychiatric nurses want to improve their relationships with individuals with BPD as evidenced by their desire for further education on BPD and evidence-based practices.Nursing students routinely encounter clients who are experiencing auditory hallucinations. This is a very subjective experience and a difficult concept for students to understand. Using the “Hearing Voices That Are Distressing” curriculum from the National Empowerment Center, Inc., featuring Pat Degan, PhD, undergraduate nursing students were asked to participate in a 3-hour simulation experience of hearing voices that are distressing, while performing activities that a client with a major mental illness might be doing. Students who have experienced hearing voices were excluded from participation. Preliminary results demonstrate that students who participate have a greater understanding of the difficulties that clients who hear voices that are distressing face in their day-to-day lives.The purpose of this presentation is to identify the need for violence prevention in acute care settings and outline a successful model implemented over a 5-year period in a Midwestern, freestanding, rural behavioral health hospital. The success of the model is demonstrated in a significant decrease in employee injuries over the 5 years and a significant decrease in seclusion and restraint over the same period of time. The model encompasses nine different aspects of the violence prevention program. This model may be generalized to any acute care setting, not just psychiatric settings. With violence on the rise in health care, this is a critical area that hospitals and particularly patient care departments need to address. The model presented has key components that lend themselves to any setting with the overriding recommendation of consistency and the need for hospitals to at least identify a model of aggression management and violence prevention.An estimated 44 million Americans experience behavioral health challenges in any given year, but only one third receive treatment. People with mental illnesses die up to 25 years earlier than the general population. They have rates two or three times higher for conditions such as diabetes, obesity, smoking, and other chronic conditions, which result in greater national economic and social costs. The Substance Abuse and Mental Health Services Administration (SAMHSA) created the 10 × 10 Wellness Campaign to address the health disparities experienced by people with behavioral health challenges and to increase their life expectancy by 10 years within 10 years. SAMHSA has partnered with the Food and Drug Administration’s Office of Women’s Health to develop the campaign’s framework for action. This session will demonstrate comprehensive, multicultural, multidimensional, and holistic approaches to physical and behavioral health that promote effective policies, practices, training, education, data and surveillance. Participants will learn about innovative, proactive, multistakeholder-developed and -delivered wellness activities that improve the lives of people with behavioral health challenges. We will address how to increase patient access to free wellness information, and encourage patient/provider dialogue to minimize the risks associated with medication use. Emphasis is placed on technical assistance and access to web-based information.Increasingly, emergency department (ED) nurses are faced with the challenge of trying to intervene and safely manage psychiatric symptoms and behaviors of pediatric patients. Research has shown that urgency at presentation in the ED is not always synonymous with clinical severity. In these cases, focus on the evaluation may shift from urgent medical conditions to the assessment of developmental level and behaviors of the child, family dynamics, or local support system. Some of the most prevalent issues encountered include child abuse/neglect, family violence, child aggression, suicide, self-injurious behaviors, substance abuse, anxiety, and mood disorders. ED nurses receive minimal training on how to recognize and manage pediatric psychiatric behaviors posing significant safety risks for the patient and the nurse. Psych APRNs can partnership with ED nurses to provide the support and expertise necessary to assess safety, suicide, and aggression risk; to evaluate symptoms of pediatric mental health; and to apply behavioral management strategies in the ED setting. They can provide accurate and timely risk assessment, recognition of pediatric mental health symptoms, knowledge of behavioral management strategies, and access to a referral network of mental health professionals, thereby helping ED personnel work more efficiently, safely, and effectively on behalf of their pediatric patients.Rational polypharmacy has become the norm in psychiatric treatment approaches for persons with multiple comorbid chronic and acute illnesses. General principles of drug–drug interactions are part of the educational foundation of all APRNs, and there are a number of electronic means to alert clinicians to potentially dangerous interactions. What is not as well known are the potential interactions that decrease efficacy of psychiatric medication treatments. In this session, we will present a series of case vignettes of common polypharmacy for psychotropic medications and medications for chronic and acute illnesses. In particular, we will highlight combinations of the classes of psychotropic agents with antibiotics, analgesics, anti-inflammatory agents, oral contraceptives, common over-the-counter medications, and specific foods. We will emphasize the cytochrome P450 (CYP450) enzymes, non-CYP450, complex CYP450, and P-glycoprotein effects on medication metabolism. In addition, strategies for learning these everyday interactions will be discussed. Acceptable medication alternatives that lead to improved efficacy and compliance will be incorporated throughout our discussion. Patient education to facilitate their self-agency and self-advocacy will be explored.Rape is a traumatic experience with significant mental health outcomes. Despite the negative impact, limited research explores the potential effect that the relationship between the victim and perpetrator has on resulting psychological outcomes. The purpose of this in progress research is to explore the associations among perpetrator/victim relationship (intimate partner, nonintimate known, stranger) and rape trauma (depression, anxiety, posttraumatic stress disorder). A convenience sample of adult women aged 18 to 64 years in the United States (n = 100) will complete the Sexual Experiences Scale (SES-SFV), Beck Depression Inventory (BDI-II), State Trait Anxiety Inventory (STAI-Y), and the Posttraumatic Stress Diagnostic Scale (PDS) via an anonymous web-based survey. Data will be analyzed using frequency distributions and correlations among the variables; multiple regression to determine if the type of perpetrator is associated with anxiety, depression, and/or posttraumatic stress disorder, including exploration of the unique contributions of each. Findings will include incidence of perpetrator/victim relationship and resulting rape trauma. Mental health providers can use this information to provide more tailored treatment approaches. Treatment implications for clinicians who assess and treat victims with unwanted sexual experiences include considerations of the perpetrator/victim relationship when recommending/making referrals for psychological support.Nonsuicidal self injury is a serious problem that typically affects individuals between the ages of 13 and 32 years with an average age of 16 years. Alarmingly, one in five adolescents has intentionally harmed themselves at some point in their life. Psychiatric nurses caring for patients who self-harm frequently become frustrated and desensitized. The challenge for health care providers is to therapeutically assist patients to better manage behaviors and help empower patients to control their self-injurious urges. This presentation will present one behavioral health hospital’s innovative evidence-based Self-Injury Prevention Protocol and the lessons learned by nursing staff throughout the implementation.APRN Licensure, Accreditation, Certification and Education (LACE) are in the midst of change. This interactive session will provide a presentation by the APRN Steering Committee, with interactive discussion of educational options and opportunities for PMHAPRNs as we move forward in our service and our careers. There will also be an opportunity for members to share the latest information about any changes in their state legislation for APRNs.The RN-PMH Council addresses practice and educational concerns of APNA psychiatric nurses at the BSN, ADN, and diploma levels. This session conducted by a panel of council members will provide a summary of the activity of the council over the past year to include progress on practice tool kits for sleep hygiene and work on the Scope and Standards of Practice for the psychiatric mental health nurse. This session is fully interactive and intended to be a venue for the nonadvanced practice psychiatric mental health nurse to network and collaborate with colleagues with similar practice experience.The Recovery to Practice Panel will highlight the work of the task force during the past year. The situational analysis process and its discoveries will be discussed within an interactive format. The proposed plan for curriculum development will be unveiled.Participants of this interactive session will join with Child and Adolescent Council members in a discussion of1. Council development and current representation2. Goals and objectives for 20113. Council accomplishments for 2011 including the following:4. Future Goals and Recommendations a. National Business Group Meeting b. Best practice recommendations for the University of Kentucky Center for the Study of Violence Against ChildrenYou asked for help with your research skills! Here it is! Based on requests from APNA members via a survey and the 2010 Research Council Interactive Panel, the CoChairs of the Research Council will provide an overview of the essential elements of grant preparation. This panel is one of several initiatives aimed at developing a research hub within APNA to support members. The American Psychiatric Nursing Foundation (APNF) grant criteria will provide the framework for this session. Didactic presentation and small- and large-group discussions will support an interactive format. Experienced researchers in both quantitative and qualitative methods will provide expertise. The facilitators will engage the audience in applying the APNF criteria to proposals for critique and refinement.Social networking, a relatively new communication phenomenon, has the ability to provide education, foster advocacy, promote the profession, and influence mental health policy. It also has the potential to violate boundaries, infringe on privacy, create liability, and damage professional credibility. A review of the literature revealed limited research has been conducted concerning the impact and use of social networking sites in nursing practice and other health care disciplines. In 2010, the ANA issued an informal resolution regarding use of social media in keeping with the code of ethics and called for additional study. In psychiatric/mental health nursing, communication is the foundation of the therapeutic alliance. Because social networking communications have the potential to positively and negatively affect this alliance, it is imperative to develop guidelines for prudent and resourceful usage of social networking media that complies with practice acts, promotes professionalism, and maintains work–life balance for the psychiatric mental health nurse. This session will provide an overview of different types of social media outlets, review published position statements from other health care disciplines, and consider best practices for psychiatric/mental health nursing.Depression is a public health problem of major significance and the most common cause of disability in North America. Studies indicate that care for depression is not optimal in either primary care or mental health settings. Lack of effective resources for teaching mental health professionals to assess and treat depression has contributed to this problem. This presentation will report on an innovative interdisciplinary collaboration to develop case-based resources, including video clips of clinical encounters, for use in educational and training programs. Two interdisciplinary work groups, one focused on children and youth and the other focused on adults and older adults, have created video-based cases and accompanying training materials to enhance assessment and treatment of culturally diverse individuals and families who experience depression. After pilot testing, these materials will be disseminated online for use by training programs. The session will describe the competencies targeted by the training materials and discuss key issues illustrated in the cases. Brief video excerpts of case vignettes will be previewed to illustrate how gender, age, and ethnic/cultural background may affect the presentation of depression, and to demonstrate effective assessment and treatment approaches.Most behavioral health organizations are engaged in some stage of educating staff about and infusing the concepts of recovery into their work with individuals. All too often a lot of effort is put into the education phase but organizations sometimes fall short in the actual implementation and infusion of recovery principles into daily practice. One indicator of how successfully staff has internalized recovery concepts is the language they use when speaking to or about the individuals they serve. The recovery process requires forming connections and is often less about the treatment individuals receive and more about the way they are treated. The language staff uses can reflect a collaborative relationship or a “them versus us” relationship that implies a culture of power and control and hinders the creation of a positive healing culture. This presentation will explore how to identify words, terms, and phrases that we need to eliminate from our vocabulary; language that hinders and helps the recovery process when talking directly to an individual and/or his family; and language used in shift report, treatment planning, and written documents such as policies, procedures, and forms, and so on.Little is known about the
Journal: Journal of The American Psychiatric Nurses Association , vol. 18, no. 1, pp. 40-62, 2012
Cumulative Annual
View Publication
The following links allow you to view full publications. These links are maintained by other sources not affiliated with Microsoft Academic Search.