Topic Falls and Fall Prevention Evidence Based Practice Change
Topic Falls and Fall Prevention Evidence Based Practice Change
Falls and Fall Prevention in Older Adults Elizabeth Hill, RN, PhD, Hill Nurse Consulting, LLC and Lynn A. Fauerbach, RN, MSN, LTAC KEY WORDS Falls, Fall Prevention, Older Adults Patient falls have a tremendous financial effect on our healthcare system resulting from increased healthcare needs and decreased reimbursement issued by insurers. More important is the devastating effect falls with serious injuries inflict on patients and their families. With increased focus on falls and fall prevention in our healthcare and legal system, it is important to know the various definitions of what constitutes a “fall,” as these depend on the setting and the corresponding regulatory body. Although the definitions are similar, considerable weight is given to interpretation. Great emphasis is placed on fall assessment tools, reflected by the number available to identify those at highest risk. Post-fall huddle tools are also available to identify system failures and areas for additional prevention strategies. Clinicians should use one that best fits the facility. Knowing about various types of falls helps nurses identify and implement the most effective, patient-specific fall prevention strategies. Education incorporating members of the expert interdisciplinary team and including proper fall risk assessment tool training
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provides the most comprehensive and effective prevention strategy possible. Falls in older adults are common. Approximately 30% of community-dwelling elders and 50% of older nursing home residents fall annually. The Center for Disease Control (CDC, 2011) estimates that every 17 seconds an older adult will require emergency medical treatment for a fall-related injury. Even more concerning: In the next 30 minutes an older adult will die from injuries sustained from the fall. The consequences of falls, particularly when alleged fall-related injuries are sustained, can have implications not only for the older adult experiencing the fall, but for their caregivers, significant others, medical providers, and healthcare and legal systems. While consequences for individuals remain the focus of clinicians, overall economic implications of falls provide a wider perspective on the scope of the problem. And the economic consequences are considerable. They include both direct costs (e.g., diagnostic work-ups, hospitalization costs, and surgery) and indirect costs (e.g., decreased quality of life, rehabilitation, and nursing home care). The Center for Medicare Services and many state Medicaid agencies recently announced they will no longer reimburse hospitals for costs associated with treating injuries sustained by patients who fall while hospitalized. The financial impact on healthcare isn’t yet fully realized, and only infrequent estimates of direct care costs have been published. Stevens et al. (2006) estimated that annual direct costs of falls in elders were approximately $19.2 billion in 2000; costs were $30 billion in 2010 (CDC, 2014). As baby boomers age over the next decades, the United States can expect the number of falls and associated costs to soar. Fall-related injuries can be minor (e.g., small laceration, abrasion, and/or bruise), major (e.g., fracture, traumatic brain injury), or even fatal. Regardless of whether an older adult sustains any injury in a fall, health care providers should evaluate for other consequences, such as fear of future falls (fallophobia). This fear might lead to older adults choosing to restrict their mobility and/or their participation in activities of daily living (ADLs) such as bathing, grooming, dressing, toileting, and walking; or instrumental activities of daily living (IADLs), which are more complex activities such as cooking, cleaning, driving and shopping. Self-restrictions in these activities can lead to further deconditioning, social isolation, and reduced pleasure or enjoyment with living. The need for more help with ADLs and IADLs may increase substantially after a fall, requiring elders in the community and their families to piece together adequate support at home or to seek a higher level of care. Long-term care arrangements such as assisted living environments or nursing homes become important considerations in cases where elders require more extensive help when current living arrangements are inadequate to maintain safety. Fall prevention is a significant challenge in long-term care environments where treatment goals include maximizing mobility and minimizing restraint. Despite the best efforts of health care professionals, all falls are not preventable. This paper will provide an overview of the various types of falls, fall risk factor assessment, current fall prevention strategies, and suggestions for the management of a patient who has fallen. Defining A Fall The definition of a fall varies, depending upon the agency or regulating body. In long-term care, the definition is in the assessment section of the long-term care minimum data set (LTCMDS), Minimum Data Set (MDS) 3.0, section J 1400 of the 3.0 Resident Assessment Instrument Manual (RAI). This defines a fall as: An unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair or bedside mat). The fall may be witnessed, reported by a resident or an observer, or identified when the resident is found on the ground. Falls include any fall whether it occurred at home, out in the community, in an acute hospital, 24 • Journal of Legal Nurse Consulting • Summer 2014 • Volume 25, Number 2 or in a nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if he or she had not caught him or herself, or had not been intercepted by another person—this is still considered a fall (CMSDC, 2010). The American Nursing Association’s National Database of Nursing Quality Indicators (ANA-NDNQI, 2014) is recognized by leading researchers for comprehensiveness regarding improving patient safety outcomes. According to the ANA-NDNQI a fall is, “an unplanned descent to the floor, or extension of the floor, (e.g., trash can or other equipment), with or without injury.” Sometimes a fall is recognized and defined according to its cause. However, incident reports or other instruments may classify a fall according to the level of harm to a resident. The International Classification of Diseases 9 Clinical Modifications (ICD-9-CM) uses broadly defined codes to categorize falls including: accidentally bumping against a moving object caused by a crowd with subsequent fall, falling from one level to another, and falling on the same level from slipping, tripping, or stumbling (Curry, 2008). For the purpose of this paper, a fall is defined as coming to rest on the ground, floor, or other lower level regardless of whether injury occurs. Types of Falls While the goal of nurses and interdisciplinary care team members (e.g. physicians, pharmacists, physical and occupational therapists, and social workers) may be to do all they can to prevent falls in patients under their care, it was recognized by Morse and others in a classic paper that not all patient falls were preventable (1987). Three types of falls outlined in the medical literature include anticipated physiological falls, unanticipated physiological falls, and accidental falls. Anticipated physiological falls are attributed to known physiological conditions and are the most common, 78% of patient falls. Morse (2009) and others found that anticipated physiological falls occur in patients who are identified by a risk assessment as being “fall prone.” An example of a fallprone patient might include an 88-year-old woman with a history of falls, on multiple medications, with impaired gait and balance, urinary incontinence, and who sometimes forgets to call for help when standing. Unanticipated physiological falls account for 8% of patient falls. According to Morse (2009), unanticipated physiological falls cannot be predicted before the first occurrence. They have medical causes such as seizures, spontaneous hip fractures, polypharmacy, and syncope, such as during an MI or CVA. An example would be a 65-yearold woman with severe osteoporosis and no prior history of falls who attempts to retrieve her cane from under her bed and falls to the floor because of a spontaneous hip fracture. Accidental falls account for 14% of falls. Accidental falls result from the patient slipping, tripping, or falling due to an environmental factor or equipment issue. Fall Risk Factors There are many factors that can identify a person at high risk for falling, with or without injury. When assessing an older adult for fall risk, as with any assessment, it is important to examine all the risk factors, since risks often potentiate one another. Any previous history of falls with their detailed descriptions is important. If there are identified circumstances in which a patient is more likely to fall, e.g., at a certain time of day, following a certain meal, or after taking certain medications, then staff can implement specific interventions to decrease the patient’s fall risk. The result could be the prevention of a fall or resulting injuries. Other identified risk factors include incontinence, impaired gait, visual changes, diminished cognition, pain, muscle weakness, and polypharmacy. Medications often identified as increasing a person’s risk for fall include: •• Opiates •• Anticonvulsants •• Antihypertensives •• Diuretics •• Laxatives •• Sedatives •• Psychotropic medications An individual may have varied responses to the same medication or to a familiar medication at a different dose. Therefore, it is important for staff to monitor the patient’s response to any medication change. Fall Risk Assessment When reviewing the medical record of an individual who has sustained an alleged fall, it is critical to have a basic understanding of fall risk. While there are many risks for falls documented in the literature, three major types of factors can put a long-term care resident at risk for falling (Hill et al., 2009). Person factors are often referred to as intrinsic risk factors. Think of these as physiological or internal characteristics specific to the individual. Examples include: •• Impaired vision •• Change in cognition •• Vertigo •• Medications identified as increasing fall risk •• Difficulty walking and/or moving from one surface to another •• History of falls •• Incontinence •• Postural hypotension •• Impulsive behavior Environmental factors are also known as extrinsic risk factors. These factors include objects that are part of the care environment (e.g. bedrails, ambulatory aids, obstacles, floor surfaces, and staffing/ratios). Journal of Legal Nurse Consulting • Summer 2014 • Volume 25, Number 2 • 25 Interactive risk factors (Hill et al., 2009) involve the person’s interactions within the long-term care environment. For example, in persons with dementia, both the time of day the resident is admitted and the change in physical surroundings could result in sundowning. Unfortunately, interactive factors are not readily integrated into published fall risk tools. In summary, fall risk is multifactorial, requiring careful, individualized, collaborative assessment with interventions to ensure resident safety in long-term care facilities. Additionally, facilities should implement standard fall prevention measures for all residents, not just those identified as being at highest risk (see Unanticipated and Accidental falls, above). Some universal fall prevention measures include: •• Placing frequently used objects within reach •• Using the top two bedrails •• Providing orientation to the room •• Adequate lighting •• Demonstrating how to use the call bell for assistance Fall Risk Assessment Tools While clinicians use many fall risk assessment tools in acute and long-term care settings, there are no guidelines recognizing one, single, best approach. Each facility should establish a standardized approach to fall risk assessment. Staff must be familiar with the adopted tool to identify residents who are at highest risk for falling. In 2004, Oliver et al. reviewed fall risk factors and assessment tools. The authors recommended using only assessment tools that have been externally validated in multiple settings. Unfortunately, this leaves very few that could be recommended for use across patient care areas. Oliver also emphasized the importance of identifying potential reversible risk factors for inpatient falls. Examples of reversible risk factors include treatment of urinary tract infections in older adults and medication review with substitution or elimination. One well-recognized tool used for many years in hospital and nursing home settings is the Morse Fall Scale (Morse, Tylko, & Dixon, 1987). This standardized approach begins with nursing staff completing one fall risk assessment consistently, at routine intervals as defined in the facility policies and procedures. Staff understanding of assessment items and response options is critical for scoring consistency. Because fall risk can be increased by a change in environment, particularly in older adults with dementia, staff should complete an initial fall risk assessment as soon as a resident is admitted to a facility, minimally within the first 24 hours. Long-term care facilities’ fall policies and protocols should provide specific guidelines for when fall risk should be reevaluated. Typically, this should occur with any change in resident condition, medications, cognitive function, after a fall, and with readmission to the facility. Even if new employee orientation covers the “how-to” of completing a fall risk assessment and the corresponding falls protocol, continued proper implementation requires periodic well-documented staff re-education or updates Users must look at a fall risk tool’s sensitivity, specificity, and inter-rater reliability in predicting falls and falls with injury. Sensitivity refers to the number of patients identified to be a fall risk that did, in fact, suffer a fall. Specificity is the number of patients determined not at risk who experienced no falls. Inter-rater reliability is important because it demonstrates that two nurses can independently obtain the same score for an individual patient’s risk. Using a valid assessment tool is the basis for implementing individualized plan of care interventions to mitigate the older adult’s identified fall risks. Fall Prevention Strategies When designing fall prevention protocols, facilities must rely on the best available evidence to ensure the highest quality patient outcomes and avoid potential litigation. The two cornerstones of successful fall prevention programs are using a standardized fall risk assessment tool properly and implementing interventions that target the individual’s specific risk factors identified by the assessment. Referrals to other disciplines can be critical. Older adults admitted because of dependence on others for ADLs must have occupational and/or physical therapy evaluations and therapy so they can perform ADLs safely. This is because studies have shown that individuals are at greater risk for falling when performing purposeful actions, such as reaching for an object or toileting (Hill et al., 2009). Nursing collaboration with physical and occupational therapy before and after initial evaluations and throughout the resident’s stay are essential to achieve the overall goal of fall prevention. Functional gait, balance, mobility, strength, cognition, and general neurological assessments are essential .A physiatrist’s comprehensive assessment of the resident’s motor abilities and limitations can be a significant asset to the care planning process. Identifying and recommending dosage changes or drug substitutions can significantly decrease a resident’s fall risk. According to 42 CFR 483.60 (j), each resident’s medications must be reviewed quarterly by a pharmacist with input from the interdisciplinary care team; irregularities must be reported to the prescribing physician and the interdisciplinary care team (eCFR, 2014). Careful evaluation of each resident’s medication profile for high fall risk medications, with the pharmacist’s recommendations for safer alternatives, can prove invaluable. Sometimes simply changing the administration time for certain medications can help reduce the risk of fall. For example, diuretics should be given early enough in the day to avoid nocturia. Diuretics given with antihypertensives can put elders at risk for orthostatic hypotension. Documenting regular postural blood pressure monitoring is also important. Some of the most important interventions for long-term care residents involve assistive devices and ADL assistance recommended by occupational and physical therapy. For 26 • Journal of Legal Nurse Consulting • Summer 2014 • Volume 25, Number 2 example, a gripper and shoe horn can help a resident avoid bending or reaching beyond the center of gravity during routine dressing. Therapists can advise staff how and when to give cues or prompts, and when to assist. Because the goal of physical and occupational therapy is to promote gradual independence with ADLs, it’s critical to strike a careful balance between over-reliance on staff assistance and resident safety. Inadequate supervision or lack of recommended nursing staff assistance can increase fall risk. These unsafe practices could be identified as potential deviations in the standard of care. Frequent Resident Checks “Hourly rounding” is being employed more frequently in hospital settings to promote patient safety, attend to basic needs, and prevent falls. In a long-term care environment, staff should check on residents at least every two hours, or more frequently depending on resident needs. During rounds, nursing staff should check the “4 Ps”: pain, potty, positioning and possessions (Meade, Bursell, & Ketelsen, 2006). When rounds are completed nursing staff should ask about the “4 Ps” and check to ensure that needs are met for those with cognitive impairment or other communication difficulty. For example, nurses should observe these residents for nonverbal expressions of pain, provide checks and changes for incontinence, reposition for comfort, and place frequently used objects within resident reach. While not all facilities require written documentation of resident rounds or checks as part of the formal medical record, such documentation by staff is certainly helpful when litigating a case. Environmental Considerations Floors in patient rooms and common areas should be checked for the following: •• Free of clutter •• Proper lighting including night lights, •• Well-maintained •• Wax free •• Free of uneven surfaces and spills •• Walking path free of multiple obstacles •• Avoid black and patterned floor surfaces Some residents with visual changes may interpret patterned flooring and areas with black flooring near elevators as holes or gaps. They may lose their balance and fall as they attempt to step over these areas. Resident rooms should be large enough to allow unrestricted mobility. Furniture should have a low center of gravity with a wide base. Placement should provide enough space within walking paths to promote safe passage of residents with assistive devices or human assist. Furniture should be stable (e.g., not gliders or rocking chairs), with arms that the resident can easily reach and hold. Bathrooms should be large enough to allow safe transfers from wheelchairs to toilets. Adjustable toilet seats decrease transfer difficulty. Grab bars near toilets and sinks can also give additional support or serve as stabilizers for safer ADLs. Any pipes within the resident’s reach or access should be padded to avoid contact related injuries (i.e., burn, tripping, and impact). Bathrooms also should have functional nightlights. Activity areas should have safe places for residents with activity intolerance to rest during ambulation. Sturdy tipproof chairs with arms are ideal and can be placed at intervals to prevent fatigue. Additions of interval seating areas are particularly important for facilities with long hallways. Well-maintained railings in hallways, placed at a standard height, can also provide intermittent support to residents and indirectly help to reduce fall risk. Monitoring Devices The traditional call bell is frequently inadequate to meet needs safely when residents are forgetful or impulsive. For these residents, a wide array of bed/chair alarms and pressure sensor mats are currently available for acute and long-term care settings. Such devices must be placed outside of the resident’s reach to prevent disabling. Staff should check and document alarm function and the resident’s response to an alarm each shift. Careful nursing documentation related to alarm use and function are critical aspects in successful defense litigation. Nursing home and assisted living facilities are installing surveillance cameras to help monitor resident safety and prevent elopement. Hallways, stairwells, and elevators are the most commonly monitored. Note that surveillance cameras alone do not prevent injury or elopement. Careful monitoring is critical, and documentation should be retained for future reference. Restraints Restraints are defined as physical or chemical restrictors of movement administered or applied by a nurse (Levin, Shanley, & Hill, 2011). Physical restraints include any devices not readily removed by the resident, such as: •• All four bedrails •• Vest •• Jackets •• Wristlets •• Anklets Physical restraints were initially used in healthcare settings to keep patients free of harm to self or others. However, researchers have noted an increase in restraint-associated falls, injuries, and death. Therefore, over the past few decades there has been an effort to reduce or eliminate physical restraints in patient care. Restraints are now a last resort, used only after other measures have been considered or used, e.g., reorientation, relocating the resident’s room to an area near the nurses’ station, bed/chair alarms or pressure sensor mats, and/ or a 24 hour sitter/continuous observation. Documentation must clearly indicate that these other restraint-free alternatives were either considered or implemented. Journal of Legal Nurse Consulting • Summer 2014 • Volume 25, Number 2 • 27 Beds and Floor Mats While placing all four bedrails up is considered a form of restraint and requires a physician or ANP prescription, two and even three rails up can be a support for bed mobility. Nursing staff can work with physical and occupational therapy to determine the most effective techniques for bed mobility, including recommendations on the number of bedrails. Resident beds should be kept locked and in the lowest position when occupied. Specialty low-beds in which mattresses are approximately 8-12 inches from the floor are in use in many nursing homes today. Low-beds are helpful for residents who have been known to roll out of bed or who have sustained injuries in falls from bed. Cushioned mats, two to three inches thick, with beveled edges lined with reflective tape, and covered by a rubberized material are also helpful for individuals who are at high fall risk and have histories of fall-related fractures. Mats with beveled/sloped edges and reflective tape assist residents in identifying changes in walking surfaces. Helmets and Hip Protectors Falls are identified as the leading cause of traumatic brain injury (TBI) hospitalizations and mortality in men and women aged 75 years or older. Special lightweight customfitted helmets or caps provide the best protection against head injuries in frequent fallers (CDC, 2014). Hip protectors provide high-impact protection for hip bones. They are available in many sizes and clothing options (e.g. undergarments, shorts, sweatpants, and incontinence briefs). Hip protectors are designed especially for individuals who are identified as a high fall risk and those with diminished bone density (i.e, osteopenia or osteoporosis). Despite widespread availability, hip pad protector quality does vary across manufacturer, and clinical trials do not conclusively support their overall effectiveness in preventing hip fracture. One of the largest challenges related to the use of hip pad protectors is adherence. Both the older adult and the caregiver must be vigilant about their use. The Centers for Disease Control (CDC) The CDC website provides numerous resources for the prevention of falls in older adult populations for both consumers and health care professionals. A tool kit called STEADI (Stopping Elderly Accidents, Deaths & Injuries) Tool Kit for Health Care Providers that can be used in both inpatient and outpatient settings is available online (CDC, 2012). After a Fall Despite diligent efforts by nursing staff to prevent falls in both acute and long-term care settings, all falls are not preventable. When an alleged fall occurs, it is critical that nursing staff respond promptly and appropriately. The nature of the response is dictated by the setting and facility protocol. For example, in acute care, a first action may be to call a “Dr. Down” or a falls code. Key nursing staff actions include: •• Obtain available information from the patient or staff about the incident •• Assess for injuries •• Notify nursing supervisor (if in fall protocol) •• Perform head-to-toe assessment, vital signs, orientation, and neurological checks •• Provide first aid as indicated •• Monitor and treat for complaints of or signs of pain •• Notify physician •• Obtain x-rays or transfer to a hospital for emergency care as indicated When a long-term care resident sustains a serious injury, such as head trauma, staff may call EMS or an ambulance before physician and/or family notification. Otherwise the family is typically notified after physician contact. Objective documentation in the medical record should follow assessment and stabilization. This should include: •• Thorough factual statement of the incident or how the resident was found •• Position in which the resident was found •• Proximity of any items or furniture •• Detailed assessment and treatment of injuries: location, appearance, size, shape, depth •• Notification of proper chain of command per facility policy (e.g. call to nursing supervisor) Debriefing the resident, staff, and other witnesses about circumstances and events surrounding the fall is also critical. The early work of Morse, Tylko, & Dixon (1987) noted the importance of a detailed post-fall assessment; they found that more than half of all second falls occurred under circumstances similar to the first fall. During staff debriefing, also known as a “huddle,” it is important to focus on any environmental clues about what the resident and/or direct care staff were doing or trying to do when the alleged fall occurred. Finally, remember: As older adults lose independence, they hold on to what they can control. It is important to strike a balance between reminding them of their limitations and encouraging their independence. Individuals should learn about their fall risk, including how to participate in their individualized fall prevention plans, if they are cognitively able. Educating family members about what they can do such as informing the nursing staff of their departure and ensuring resident’s personal items are within reach may be enough to prevent a fall. Conclusion Fall risk assessments are not “one-size-fits-all” or the sole answer to fall prevention. When considering a fall risk assessment for use, facilities or staff must first evaluate the reliability and validity of the tool for use with their population. Once they select a tool to use, they should develop a comprehensive set of evidence-based interventions for each area in the fall risk assessment. Careful staff education planning 28 • Journal of Legal Nurse Consulting • Summer 2014 • Volume 25, Number 2 and reevaluation for periodic re-education are also integral to any successful fall prevention protocol. Coordinated effort involving all interdisciplinary team members is critical to the safety of older adults in all settings. References American Nursing Association’s National Database of Nursing Quality Indicators (ANA-NDNQI, 2014) Centers for Disease Control & Prevention (2012a). The Cost of Falls Among Older Adults. Retrieved from CDC website: http:// www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html Centers for Disease Control & Prevention (2012b). Help Seniors Live Better, Longer: Prevent Brain Injury. Retrieved from CDC website: http://www.cdc.gov/traumaticbraininjury/seniors.html Center for Medicare and Medicaid Services, (January 2010), Resident Assessment Instrument Manual, 3.0 Retrieved from CMS website. http://www.cms.gov/Medicare/ Quality- Initiatives-Patient-Assessment-Instruments/ NursingHomeQualityInits/MDS30RAIManual.html Curry, L. (2008). Fall and Injury Prevention. Chapter 10, In Hughes, R.G. Inpatient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality, Rockville, AHRQ Publication No. 08-0043. Electronic Code of Federal Regulations (2014). 483.460 Condition of participation: Health care services. (j) Standard: Drug regimen review. In Title 42: Public Health Part 483 Requirements for States and Long Term Care Facilities. http://www.ecfr.gov/cgi-bin/text-idxSID=a728c067cd94252edfc 024d9996450c4&node=42:220.127.116.11.18.104.22.168&rgn=div8 Hill, E. E., Nguyen, T. H., Shaha, M., Wenzel, J. A., DeForge, B. R., & Spellbring, A. M. (2009). Person-Environment Interactions Contributing to Nursing Home Resident Falls. Research in Gerontological Nursing, 2(4), 287-296. Levin, B., Shanley, K., & Hill, E. E. (2011). Falls and their consequences. In P. Iyer, B. Levin, K. Ashton and V. Powell, Nursing Malpractice (4th ed). Lawyers & Judges. Tucson, AZ. Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds: on patients’ call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70. Morse, J. M. (2009). Preventing patient falls: Establishing a fall intervention program, (2nd ed.). Springer, New York. Morse, J. M., Tylko, S.J., & Dixon, H.A. (1987). Characteristics of the fall-prone patient. Gerontologist, 27(4), 516-522. Oliver, D., Fergus, D., Martin, F.C., & McMurdo, M. E. (2004). Risk factors and risk assessment tools for falls in hospital inpatients: a systematic review. Age & Ageing, 33(2), 122-130. Elizabeth Hill is the owner of Hill Nurse Consulting LLC in Woodstock MD. She may be reached at firstname.lastname@example.org. Lynn Fauerbach may be reached at LTAC Long Term and Sub-Acute care in Bel Air MD, email@example.com. Call for Case Study Authors – Don’t Miss This Opportunity – Submit Today! Have you worked on a case that could provide information and help for other LNCs? Is there a case you have worked on that was especially interesting or instructive? Are you looking for an opportunity to “get published”? If the answer to any of these questions is “yes”, we invite you to submit your case study abstract today to be considered for publication. Why should I submit a case study abstract? As a case study author, you will contribute to the general body of knowledge for legal nurse consultants. You will be making a valuable contribution both to AALNC and to the profession. 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Journal of Legal Nurse Consulting • Summer 2014 • Volume 25, Number 2 • 29 Copyright of Journal of Legal Nurse Consulting is the property of American Association of Legal Nurse Consultants and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.
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