PICOT and EBP Assignment: Finding the Research Evidence

PICOT and EBP Assignment: Finding the Research Evidence
PICOT and EBP Assignment: Finding the Research Evidence
Continuing on with step one of the Impact Model is the need to search for the studies to support your project. There are different classes of evidence that can guide changes in clinical practice.

To prepare for this Assignment, review the following:

Write a 2-page paper (exclusing title page and reference page) to address the following:

• For the evidence-based problem that you identified in Week 1 for your project, locate two different articles/sources representing two different types of evidence from the following categories: (a) systematic review, (b) national clinical guidelines and/or (c) peer-reviewed quantitative / qualitative studies. PICOT and EBP Assignment: Finding the Research Evidence.
• For each article/source of evidence:

o Summarize the article/source in your own words without the use of direct quotes.

o Using the Peterson et al., (2014) article located in Week 2 Resources address the level of evidence (hierarchy). Then discuss the usefulness of the evidence from the article/source in addressing the identified practice problem. Be sure to site evidence in-text and in a final reference page.

o Describe where your two sources fit into the hierarchy of evidence and explain why PICOT and EBP Assignment: Finding the Research Evidence.

o Describe the value of these two sources in better understanding and addressing your evidence-based problem.
Evidence-Based Practice Paper Guide
 Impact Model
(Source:  Brown, S. (2014). Evidence-based nursing: The research practice connection.  Burlington, MA:  Jones and Bartlett Learning.) PICOT and EBP Assignment: Finding the Research Evidence.
Step 1                  Ask and Search

ASK– identify evidence-based practice (EBP) question

Write in PICO format
P –  patient population
I  –  intervention/issue
C – comparison intervention
O – outcome(s)
For example, in patients with acute myocardial infarction, does ambulation within the first 24 hours as compared to those who remain on bed rest for the first 48 hours result in increased participation in cardiac rehabilitation following discharge from the hospital?
Be sure to have your project approved by your Instructor before continuing with the steps.
Assignment Week 1:  Submit the completed Evidence-Based Problem and Question Template to the Week 1 Assignment link. (Refer to the grading rubric in Course Information for assignment details.)


Identify search terms and search engines.  Find a minimum of five EBP articles that have been published within the last 5 years.  Be sure to look at the systematic reviews and the national clinical practice guidelines. PICOT and EBP Assignment: Finding the Research Evidence.
Assignment Week 2:  Submit a 1- to 2-page paper describing two sources

of evidence you have found, where they fit in the hierarchy of evidence, and the value of these sources in better understanding your evidence-based practice problem.  Summarize the findings in the literature that you retrieved. Submit to the Week 2 assignment link. (Refer to the grading rubric in Course Information for assignment details.)
Step 2                        Appraise the literature
Critique each article using the appropriate Appraisal Guide provided in Week 4 Resources. In the final paper, a critique of at least five of the articles used for your project will need to be submitted.
PICOT and EBP Assignment: Finding the Research Evidence Assignment Week 4:  Submit critiques of two of the articles using the appropriate Appraisal Guide provided to the Week 4 Resources. (Refer to the grading rubric in Course Information for assignment details.)
Step 3                         Design the project
Describe each step of the project clearly and completely.  Clearly explain the recommended evidence-based change including the setting, health care consumers affected, and the rationale for the change.
Assignment Week 5:  Submit a 2- to 3-page paper discussing your EBP plan.  Include the PICO clinical question, recommended change in practice, and the evidence to support the plan. (Refer to the grading rubric in Course Information for assignment details.)
Step 4                          EBP
The final step is to discuss how the outcomes from the plan will be evaluated.  Identify the criteria that will be used to measure the effectiveness of the change.  For example, how many individuals following an acute myocardial infarction are participating in or have participated in the cardiac rehabilitation program? The final EBP plan needs to be developed into a power point for posting in the classroom. PICOT and EBP Assignment: Finding the Research Evidence.
Assignment Week 6: Develop a voice over PowerPoint presentation.
Post the presentation in the Week 6 Discussion board by Day 3. Use the week 6 submission link to submit the final copy of the PowerPoint to your Instructor for grading. (Refer to the grading rubric in Course Information for assignment details.)

he idea of sharing clinical experiences to improve patient care is not new to

nurses. Florence Nightingale published her observations on cleanliness, nutrition,

and fresh air in Notes on Nursing1 in 1860. Her work was the start of evidence-based

nursing practice. More than 150 years and thousands of research studies later, the

use of evidence to guide nursing practice is the expected standard of practice for both

individual nurses and health care organizations. Scope and Standards of Practice2 and Code of Ethics3

of the American Nurses Association both call for nurses to incorporate research evidence into

clinical practice. Schools of nursing have added content on evidence-based practice to their curricula.4 Despite these efforts, barriers inhibit implementation of changes based on published evidence

into bedside patient care. Overall, the barriers involve the characteristics of the nursing profession,

organizational dynamics, and the nature of the research.5,6 Studies7,8 have consistently indicated

that a nurse’s inability to both determine what evidence is ready for implementation into practice

and then successfully develop processes to sustain an evidence-based practice change is a barrier.

Choosing the Best PICOT and EBP Assignment: Finding the Research Evidence

Evidence to Guide Clinical

Practice: Application of

AACN Levels of Evidence








©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014411

Evidence-Based Practice

Evidence-based nursing care is informed by research findings, clinical expertise, and patients’ values, and its

use can improve patients’ outcomes. Use of research evidence in clinical practice is an expected standard of

practice for nurses and health care organizations, but numerous barriers exist that create a gap between new

knowledge and implementation of that knowledge to improve patient care. To help close that gap, the American Association of Critical-Care Nurses has developed many resources for clinicians, including practice alerts

and a hierarchal rating system for levels of evidence. Using the levels of evidence, nurses can determine the

strength of research studies, assess the findings, and evaluate the evidence for potential implementation into

best practice. Evidence-based nursing care is a lifelong approach to clinical decision making and excellence in

practice. (Critical Care Nurse. 2014;34[2]:58-68)

58 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org

In this article, we provide a brief history of the involvement of the American Association of Critical-Care

Nurses (AACN) in evidence-based practice, explain the

recent clarifications added to the 2009 AACN levels of

evidence, and provide examples of how to change bedside practice in the clinical setting.

History of AACN Involvement in

Evidence-Based Practice

Currently, AACN is the largest specialty nursing

organization and a leader in the movement to improve

patient care by applying the best scientific evidence. In

1995, AACN began to publish Protocols for Practice, an

evidence-based resource for clinical nurses. Each protocol provides a guide for appropriate selection of patients,

use and application of management principles, initial

and ongoing monitoring, discontinuation of therapies

or interventions, and selected aspects of quality control.

The protocols have covered topics such as hemodynamic

monitoring and care for patients treated with mechanical

ventilation. Subsequently, a volunteer workgroup was

formed to connect clinicians with research to improve

care of critically ill patients. The original research workgroup, known since 2007 as the Evidence-Based Practice

Resources Workgroup (EBPRWG), focused on developing resources that synthesized current research. Resources

were made readily available and in an easy-to-use format

for use in care decisions at the bedside (eg, laminated

pocket-sized cards for clinicians). The work of this group

has continued for more than 2 decades. Current products available to AACN members include protocols for

practice; practice alerts with tool kits, PowerPoint presentations, and audit tools; pocket card references; and

defined levels of evidence for clinical nursing practice.

Evolution of AACN Levels of Evidence

The amount and availability of research supporting

evidence-based practice can be both useful and overwhelming for critical care clinicians. Therefore, clinicians

must critically evaluate research before attempting to put

the findings into practice. Evaluation of research generally occurs on 2 levels: rating or grading the evidence by

using a formal level-of-evidence system and individually

critiquing the

quality of the

study. Determining the

level of evidence is a key

component of

appraising the evidence.5,9,10 Levels or hierarchies of evidence are used to evaluate and grade evidence. The purpose of determining the level of evidence and then

critiquing the study is to ensure that the evidence is credible (eg, reliable and valid) and appropriate for inclusion

into practice.10 Critique questions and checklists are

available in most nursing research and evidence-based

practice texts to use as a starting point in evaluation.

The most common method used to classify or determine the level of evidence is to rate the evidence according to the methodological rigor or design of the research

study.10,11 The rigor of a study refers to the strict precision

or exactness of the design. In general, findings from

experimental research are considered stronger than findings from nonexperimental studies, and similar findings

from more than 1 study are considered stronger than

results of single studies. Systematic reviews of randomized controlled trials are considered the highest level of

evidence, despite the inability to provide answers to all

questions in clinical practice.11,12 For example, AACN

and other organizations have done extensive research

on healthy work environments. This topic would not be

examined in a randomized controlled trial because of

ethical and practical considerations. Randomly assigning nurses to work in various healthy or unhealthy work


Mary H. Peterson is an educator for Elsevier, Inc Live Review and

Testing, Houston, Texas and a cardiovascular clinical nurse specialist.

Susan Barnason is director of the DNP program at the University of

Nebraska Medical Center in Lincoln.

Bill Donnelly is a critical care staff nurse at Cooley Dickinson Hospital,

Northampton, Massachusetts.

Kathleen Hill is a clinical nurse specialist in the surgical intensive

care unit at Cleveland Clinic, Cleveland, Ohio.

Helen Miley is a specialty director adult-gero acute care nurse practitioner at Rutgers, The State University, Newark, New Jersey.

Lisa Riggs is director of cardiovascular quality at Saint Luke’s Hospital

of Kansas City, Kansas City, Missouri.

Kimberly Whiteman is codirector of the DNP program at Waynesburg

University, Waynesburg, Pennsylvania.

Corresponding author: Mary H. Peterson, 543 Westwood Road, Alexander City, AL

35010 (e-mail: [email protected]).

To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)

362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

www.ccnonline.org CriticalCareNurse Vol 34, No. 2, APRIL 2014 59

The purpose of determining the level of

evidence and then critiquing the study is

to ensure that the evidence is credible

(eg, reliable and valid) and appropriate

for inclusion into practice.

environments could have an adverse effect on the quality

and safety of patients receiving care. Therefore, most of

the studies on healthy work environments have involved

descriptive or qualitative study designs. Although the less

rigorous design places descriptive and qualitative studies

at a lower level than that of randomized control trials on

the AACN rating system, the lower level is the highest

level of evidence that the information on healthy work

environments can ethically and practically provide.

AACN Evidence-Rating System

As interest in promoting evidence-based practice has

grown, many professional organizations have adopted

criteria to evaluate evidence and develop evidence-based

guidelines for their members.5,12 A task force formed by

AACN developed the organization’s original rating scale,

which used Roman numerals; lower numerals represented

lower levels

of evidence. In

1995, the

time of the

original AACN rating scale, only a few other organizations had published levels of evidence. Other professional

hierarchies used a reverse order, with lower Roman

numerals reflecting higher levels of evidence. This difference led to confusion among practitioners who were trying to use the original rating system in the clinical setting.13

In 2008, AACN challenged the EBPRWG to review the

rating system and make recommendations for improvement. The result was an alphabetical hierarchy in which

the highest form of evidence was ranked as A and included

meta-analyses and meta-syntheses of the results of controlled trials. Evidence from controlled trials was rated

B. Level C evidence included findings from studies with

a variety of research designs (Table 1). As in the previously published rating system, the 2008 system included

results of theory-based evidence, expert opinion, and

multiple case reports as level E evidence. Rapid

advances in technology resulted in many products being

used solely on the basis of the manufacturers’ recommendations. M was used to represent the body of practice recommendations provided by industry.14

When the 2008 hierarchy of evidence was published,

AACN welcomed feedback from its members about the

changes. Since then, members have asked for clarification on the hierarchy, particularly an explanation of the

rating of systematic reviews. Most rating systems rank

systematic reviews of well-designed randomized controlled trials as the highest level of evidence. Many members thought that systematic reviews were misplaced at

level C within the AACN levels of evidence. The request

for clarification was referred to the 2011 annual meeting

of the EBPRWG for review and discussion.

Changes to the AACN Levels of

Evidence in 2011

The 2011-2012 EBPRWG responded to the concerns of

AACN members by revising the 2008 levels of evidence.

In recognition that the strength of a systematic review

depends on the rigor of the studies included in the review,

the workgroup distinguished between the 2 types of systematic reviews: randomized control trials and reviews of

other studies. Systematic review of randomized controlled


Experimental evidence










Meta-analysis or metasynthesis of multiple controlled studies with results that consistently support

a specific action, intervention, or treatment (systematic review of a randomized controlled trial)

Evidence from well-designed controlled studies, both randomized and nonrandomized, with results

that consistently support a specific action, intervention, or treatment

Evidence from qualitative, integrative reviews, or systematic reviews of qualitative, descriptive, or

correlational studies or randomized controlled trials with inconsistent results

Evidence from peer-reviewed professional organizational standards, with clinical studies to support


Theory-based evidence from expert opinion or multiple case reports

Manufacturer’s recommendation only

Table 1 2012 American Association of Critical-Care Nurses levels of evidence with revisions to 2008 hierarchy

60 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org

Clinicians must determine the clinical relevance

of the research (ie, if the results are applicable

to and feasible in clinical practice).

trials was added to level A, the highest level of evidence.

This change makes the AACN system consistent with

other published hierarchies used to rate evidence (eg,

American Heart Association15). Systematic reviews of

qualitative, descriptive, or correlational studies remained

within level C, the highest level for nonexperimental

studies. Also, the distinction between experimental and

nonexperimental studies in the hierarchy was clarified.

A schematic was developed to illustrate that levels

A and B are for studies with an experimental design.

Levels A, B, and C are all based on research (either experimental or nonexperimental designs) and are considered

evidence. Levels D, E, and M are considered recommendations drawn from articles, theory, or manufacturers’ recommendations (see Figure). Table 2 gives an

overview of the different types of research study designs

and the definitions that were used by the workgroup

to guide placement of study designs within the levels of

evidence system.

Levels of Evidence and

AACN Practice Alerts

The level of evidence is used to rate the strength of

the study design, but it does not give clinicians information about relevance to practice. In addition to rating

the studies on the basis of the design used, clinicians

must also analyze and critique the individual studies for

strengths and weaknesses. For instance, the results of a

randomized controlled trial (level B) that did not follow

strict criteria for selecting participants or patients might

be biased. The findings of this type of study would not

be as strong as those of a randomized controlled trial in

which adherence to random selection was rigorous.

Before implementing research into practice, clinicians

Figure American Association of Critical-Care Nurses evidence-based care pyramid: levels of evidence 2012.

a Experimental: testing the effects of an intervention or treatment on selected outcomes.

b Nonexperimental: data are collected, but not to test the effects of an intervention or treatment on specific outcomes.

Based on data from Melnyk and Fineout-Overholt.10

A and B: Experimentala

C, D, E, and M:


A, B, and C: Evidence-based


D, E, and M:

Expert opinion or









www.ccnonline.org CriticalCareNurse Vol 34, No. 2, APRIL 2014 61

should examine individual studies to determine if the

results were obtained by using sound (reliable and valid)

scientific methods. Last, clinicians must determine the

clinical relevance of the research (ie, if the results are

applicable to and feasible in clinical practice). This evaluation or critique takes time to complete and is a learned

skill that is developed with guided practice.

The purpose of each AACN practice alert is to

address both nursing and multidisciplinary activities of

importance. The topic selected for each alert is important to the care of acutely and critically ill patients or

their environments. Practice alerts do the following:

• Close the gap between research and practice

• Provide guidance

• Standardize practice

• Identify and inform about new advances and

trends AACN practice alerts are defined as “succinct,

dynamic directives supported by authoritative evidence

to ensure excellence in practice and a safe and humane

work environment.”16 The alerts are short directives

designed for easy reference. Each one includes the

scope and impact of a problem or topic, expected practice and nursing actions, supporting evidence for

change, additional resources for implementation, and

references. Because practice is dynamic, the practice

alerts are reviewed and updated to reflect any researchbased changes.16

To help members use research findings and apply

them to practice, AACN began to develop practice alerts

that present an overview of the current research evidence

62 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org

Level of











Type of study


Systematic review

If quantitative study

If qualitative study


controlled trial

Cohort study



Integrative review


Qualitative research


A technique for quantitatively integrating the results

of multiple similar studies addressing the same

research question

A rigorous synthesis of research findings on a

particular research question obtained by using

systematic sampling and data collection procedures and a formal protocol

A full experimental test of an intervention, involving

random assignment to treatment groups

A nonexperimental design in which a group of

people (a cohort) is followed over time to study


A nonexperimental research design involving the

comparison of a case and a matched control5

Reviews of qualitative studies, often taking the form

of metasyntheses, which are rich sources for

evidence-based practice

Interpretive translations produced from the

integration or comparison of findings from

qualitative studies on a specific topic

Investigation of phenomena, typically in an

in-depth and holistic fashion, through the

collection of rich narrative materials by using a

flexible research design


Statistical summary of articles of the same topic in research;

process of using quantitative methods to summarize the

results from multiple studies

Review by experts in the field of all the research on a

topic, who rigorously appraise the studies and offer the

conclusion to support an intervention or not

True experimental study in which the researchers are often

blinded to which patients or participants are receiving an

intervention; the strongest design for examining the

cause and effect of an intervention; reduces bias

Prospective longitudinal study that examines 2 groups of

patients or participants (the cohort)

Longitudinal study that retrospectively compares characteristics of an individual who has a certain type of condition that may not be very common; often used to

identify variables that may predict the etiology or the

course of a disease

Compilation of studies that are reviewed and summarized;

may incorporate research and nonresearch articles

Compilation of qualitative studies looking for the common

themes among similar research studies

Method to develop a greater understanding of a topic using

many different methods such as observation or interview

Table 2 Level of evidence, types of research studies, definitions, strengths, limitations, and examples

a Based on Polit and Beck.5 In an experimental design, the researcher controls the variable by randomly assigning patients or participants to different treatment conditions.

In nonexperimental studies, the researcher collects data without introducing an intervention (also called observational).

in a practical, easy-to-read guide for critical care nurses.

The first practice alerts were published in 2004.

A process was developed to ensure that the alerts

represent a translation of evidence and best practices.

Ideas for topics are generated from questions that AACN

members have asked the organization’s clinical practice

experts, AACN leaders, other members, and/or the

EBPRWG. A modification of the Delphi technique, a

widely used method for achieving unified opinion, is used

to rank the importance of clinical questions. Criteria for

ranking include incidence, prevalence, patient care implications, and timeliness.

After topics are generated, the EBPRWG and AACN

determine the names of experts in the clinical area of

interest and commission the writing of the practice alert.

Using standard guidelines prepared by AACN, the clinical experts write the practice alert and submit it to the

EBPRWG for review and feedback. EBPRWG members

seek feedback from their clinical peer network to assess

the congruency of the proposed practice alert with clinical practice and available research. Clinicians are also

asked to comment on the applicability of the practice

alert’s recommendations to patient care.

When the clinical review has been completed, revisions are completed if indicated. Then, communications

experts at AACN prepare the practice alert for distribution to AACN members via the AACN website. Sample

PowerPoint presentations to be used for education are

prepared and can be downloaded for immediate use

(eg, see the presentation for venous thromboembolism

www.ccnonline.org CriticalCareNurse Vol 34, No. 2, APRIL 2014 63

PICOT and EBP Assignment: Finding the Research Evidence Limitations

Usually lengthy; combines like research studies

Only as good as the search methods and

databases used


May require more sophisticated statistical



No intervention performed

May include attrition


Not as rigorous as systematic reviews; review

limited to the literature

Interpreted by the researcher

Some believe it to be less rigorous


Cochrane Reviews

Coventry et al

Sex differences in symptoms presentation in acute myocardial infarction: a systematic review

and meta-analysis. Heart Lung. 2011;40(6):477-491.

Colnaghi et al

Nasal continuous positive airway pressure with heliox in preterm infants with respiratory

distress syndrome. Pediatrics. 2012;129(2):e333-e338.


The relationship of work, self-care, and quality of life in a sample of older working adults

with cardiovascular disease. Heart Lung. 2012;41(1):5-14.


Predictors of pressure ulcers in adult critical care patients. Am J Crit Care. 2011;20(5):364-375.


Opioid tapering in children: a review of the literature. AACN Adv Crit Care. 2010;21(2):139-145.

Palacious-Ceña et al

Patients, intimate partners and family experiences of implantable cardioverter defibrillators:

qualitative systematic review. J Adv Nurs. 2011;67(12):2537-2550.

Hall et al PICOT and EBP Assignment: Finding the Research Evidence

The experiences of patients with pulmonary artery hypertension receiving continuous intravenous infusion of epoprostenol (Flolan) and their support persons. Heart Lung.


prevention17). Audit tools to help monitor compliance

with a change in practice are provided and help clinicians determine if a change is being implemented as

planned. For example, the audit tool for venous thromboembolism prevention provides 3 questions to use

during a chart review to determine if best practices have

been implemented at the bedside.17

Understanding how the evidence in a practice alert is

evaluated and how the recommendations are made provides users the confidence to implement the Actions for

Practice section of the practice alert in individual care

settings. Case 1 is an example of a practice alert and how

information in the alert might be used in clinical practice.

Published practice alerts are reviewed and revised by

the EBPRWG on a cyclical basis (at least every 3 years)

to determine the relevance to practice, the need to

update the references, and to ensure that the recommendations reflect the current evidence. Each practice

alert is reviewed and evaluated by selected members of

the EBPRWG by using a standardized evaluation tool.

The findings are shared with the 10-member EBPRWG

for feedback. Recommendations are made to continue

publishing the practice alert with minimal changes or

to make major revisions based on new evidence. Either

the original expert author or a newly commissioned

expert completes major revisions, and the practice alert

goes through the approval process as if it were a new alert.

Future new and revised practice alerts will also

include information on the search strategy used for the

systematic review conducted by the author of the practice

Some staff members in the intensive care unit

(ICU) wanted to modify the visitation guidelines

for the unit and so approached the nurse manager with their concerns. Many families of ICU patients

desire unrestricted contact with their loved one, and

the hospital guidelines currently allowed 24/7 family

presence in the ICU. However, patients cannot always

communicate their desire for family presence. Some

nurses in the unit were concerned about patient privacy and interruption of therapies, whereas others welcomed the 24/7 family presence. The manager

reviewed the AACN practice alert on family presence in

the adult ICU18 and did the following:

1. Summarized the 4 expected practices in the alert

and compared them with the ICU’s policies.

• Facilitate unrestricted access to hospitalized

person for a chosen support person

• Ensure that hospital policy promotes the presence of a chosen support person

• Evaluate policies to be sure they are nondiscriminatory

• Establish policies to limit family presence when

safety is a concern or presence would be

detrimental to medical therapies

2. Shared the Supporting Evidence section from the

practice alert with the staff members who raised

concerns about the current policy. Discussed the

recommendations for nursing actions and tried to

help the staff gain perspective on the controversies and history behind the recommendations.

3. Asked staff/unit governance members (practice

council) to develop recommendations based on the

Actions for Nursing Practice in the practice alert.

• Are there practices that could be adopted

from the recommendations?

• Is there an opportunity to introduce this topic

during orientation?

• Are there other units who would want to collaborate on this issue?

• Is there a compliance problem with visitation/presence on the part of staff or on the

part of visitors?

After deliberation and discussion, the nurses who

originally brought up the concerns identified several

practice areas on which to focus. They convinced the

nurse educator and preceptors to add content from the

practice alert on family presence in the ICU to the orientation checklist. A multidisciplinary team, including the

medical director and a social worker, participated in

enhancing and clarifying the visitation policy. Staff members determined that the mandate for open access had

caused the original dissatisfaction. After review, they

found a way that fit their workflow to identify the family

spokesperson and communicate the current evidence.


Using a Practice Alert to Revise Current Practice

64 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org

alert. This useful information allows the user to examine

the comprehensiveness of the review, databases searched,

publication years included in the search, and the specific

search terms that were used in deriving the evidence

reported in the recommendations of the alert.19-21

With practice alerts, critical care nurses have evidencebased guidelines and implementation strategies at their

fingertips and know the strength of the evidence on

which the recommendations were based. Case 2

describes using the AACN practice alert on delirium22 to

Patients are often hospitalized and admitted

to critical care units unexpectedly because of

life-threatening illnesses. After admission, the

patient’s environment, daily routines, and control of

activities of daily living are completely changed. The clock

and calendar on the wall are both reminders of time

and date, but the surroundings and


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