RAM menopause

Application of Roy’s Adaptation Model When Caring for a Group of Women Coping

With Menopause

Denise A. Cunningham, RN, BScN

D’Youville College

This article details the application of Roy’s (Roy & Andrews, 1999) adaptation model when caring for a group of women experiencing changes associated with menopause. The Roy model guided the assessment of the members’ levels of adaptation and facilitated the man- agement of stimuli to promote their adaptation. Nursing interventions focused on issues sur- rounding menopause including disturbance in body image and social isolation.

The life expectancy of the average Canadian woman is 81 years (Statistic s Canada, 1999). This increased longevity is allowing a greater number of women to experience the joys and sorrows of life after menopause. Although some women start to think about meno- pause early in life, others avoid the topic altogethe r until they are faced with its physical symptom s and biologica l changes (Choi, 1995). Community health clinical nurse special- ists can play an important role in assistin g women to adapt to menopause . The purpose of this article is to describe how one nurse facilitate d a group for women coping with meno- pause. The Roy (Roy & Andrews, 1999) adaptation model guided the assessment, diagno- sis, planning, implementation, and evaluation of care for this group.

LITERATURE REVIEW

There are a number of publishe d articles and studies on menopause , its symptoms, and treatments. The following is a synthesi s of the literature used to plan care for and educate the women’s group about menopause . The North American Menopause Society’s (1999) guideboo k provide d general information on the physica l and emotional changes that often accompany menopause as well as the myriad of treatment options available to women. On a more clinical level, Rousseau (1998) offered an in-depth review of the endocrinolog y of menopause and the histor y of menopause treatment during the past century. Whereas four

JOURNAL OF COMMUNITY HEALTH NURSING, 2002, 19(1), 49–60 Copyright © 2002, Lawrence Erlbaum Associates, Inc.

Requests for reprints should be sent to Denise A. Cunningham , 11 Nahanni Terrace, Scarborough, On- tario, Canada M1B 1B7. E-mail: [email protected]

studies provided an analysis of women’s knowledge of and attitude s towards menopause (Avis, Kaufert, Lock, McKinlay, & Vass, 1993; Avis & McKinlay, 1995; Kaufert, Boggs, Ettinger, Woods, & Utian, 1998; Utian & Boggs, 1999), one article offered eloquent state- ments from women to illustrat e the various perspectives on the menopausa l transitio n (Choi, 1995).

The changes that accompany menopause may threaten a woman’s body image and promote feelings of social isolation . Information on natural approaches to manage the physical symptoms of menopause (Weed, 1999) and the use of dietary intervention s and exercise to influence how the body looks were found in a variety of resources and shared with group members (Dossey, 1995; Health Canada, 1992, 1998; Jakicic, Winters, Lang, & Wing, 1999; Snelling & Stevenson, 1999). Strategies to encourage adaptive coping be- haviors by promoting spiritual and physical well-being were obtained primarily from two articles (Schaub & Schaub, 1999; Scura & Whipple, 1997).

The literatur e suggests that women differ in the extent to which they experience the bi- ological, psychological , and social changes that accompany menopause . The challenge for community health clinical nurse specialist s is to identify women for whom meno- pause is an uncomfortabl e experience and assist those women in the development of adaptive responses (Avis et al., 1993).

ROY ADAPTATION MODEL

The Roy (Roy & Andrews, 1999) adaptation model has served as a framework for practice in a variety of settings includin g oncology (Piazza, Foote, Holcombe, Harris, & Wright, 1992), surgery (Dunn & Dunn, 1997), and community health (Dixon, 1999). The model was chosen as the framework for assessing and planning care for the women’s group be- cause of its holistic perspectives on individuals and the process of adaptation .

The Roy (Roy & Andrews, 1999) adaptation model viewed individual s as holisti c adaptive systems who respond to different stimuli in the environment . The individuals ’ responses to a constantl y changing environment are dependent on their coping processes. This model categorized coping processes into two subsystems, the regulator and the cognator. In the regulator subsystem , individual s respond to environmenta l stimuli auto- matically through innate, physiologica l adaptive processes. The regulator subsyste m processes changes in the environment through neural-chemical-endocrin e channels to produce responses. In the cognator subsystem , individual s respond to stimuli from the environment that involve psychological , social, physical, and physiologica l factors, in- cluding regulator subsyste m outputs (Fawcett, 1989). The cognator subsyste m processes changes in the environment through cognitiv e and emotional channels that involve per- ceptual and information processing , learning, judgement, and emotion. Together, both the regulator and cognator subsystem s work to respond to changing internal and external stimuli and maintain the integrity of the individual .

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The Roy (Roy & Andrews, 1999) adaptation model described three types of stimuli that form the environment and affect adaptation . These stimuli are focal (immediately confrontin g the individual) , contextual (all other stimuli present in the situation) , and re- sidual (factors influencin g behavior, but their effects cannot be validated). When individ - uals are confronted with stimuli, their coping processes, by way of the regulator and cognator subsystems , are activated and manifested within one or more of Roy’s four adaptive modes (Piazza et al., 1992). According to Roy and Andrews, the adaptive modes include the biologica l or physiologica l mode of adaptation and three psychosocia l modes, which are the self-concept mode, role function mode, and the interdependenc e mode. The regulator subsyste m is related primarily to the physiologica l mode, whereas the cognator subsystem is related to all four adaptive modes.

An individual ’s behavioral response to stimuli in the environment can be either adap- tive or ineffective (Roy & Andrews, 1999). Adaptive responses promote integrity and help to meet the goals of adaptation , which include mastery, survival, growth, and repro- duction (Piazza et al., 1992). Ineffective responses, on the other hand, do not promote in- tegrity of the individual and do not contribute to the goals of adaptation .

In the Roy (Roy & Andrews, 1999) adaptation model, health was perceived “as a state and a process of being and becoming an integrated and whole human being” (p. 54). The goal of nursing is to promote health, in each of the four adaptive modes, by maintainin g adaptive responses and converting ineffective responses to adaptive ones. To achieve the goal of nursing, nurses use the nursing process to assess an individuals ’ adaptation level and coping processes within the regulator and cognator subsystems , to identify prob- lems, and to implement a plan of care that promotes their adaptation (Dixon, 1999). The nursing process in the Roy adaptation model involve s six steps: assessment of behavior , assessment of stimuli, formulation of a nursing diagnosis , goal setting, intervention , and evaluation.

ASSESSMENT

The group consisted of three women in a closed group format and was categorized as a supportiv e or therapeutic group (Clark, 1994). The women were Jamaican-Canadian, middle-aged, and menopausal. The group met for six sessions , with each session 2½ to 3 hr in length. Based on the recommendation of group dynamic theory (Clark, 1994), the lo- cation of the meetings was readily accessible to all members, and the meetings were held in a room where members could sit comfortably and discuss their issues privately.

First-Level Assessment

Data collection was the main focus of the first two group sessions . According to the Roy (Roy & Andrews, 1999) adaptation model, nursing assessment involves a first-level and

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second-level assessment. In the first-leve l assessment, the nurse collects information about the individuals ’ behaviors, in relation to the four adaptive modes, and determines their current state of adaptation . During the first group session, discussions , observations , and the completion of a self-assessmen t tool facilitated the collection of assessment data. The self-assessmen t tool from Dossey and Keegan (1995) gathered information about each member’s physical, mental, emotional, and spiritua l status and also provide d an as- sessment of each member’s relationship s and choices. Discussion s during the first group session explored, in detail, what menopause meant to each member and the problems faced by them as they had journeyed through menopause .

Physiologic mode. According to Roy and Andrews (1999), the physiologi c mode deals with the system’s need for physiologi c integrity . Five needs relative to physiologi c integrity include oxygenation , nutrition , elimination, activity and rest, and protection . With respect to the women’s group, the basic need of oxygenatio n was judged as not threatening to the members’ goals of adaptation . First-level assessment for the other four basic needs, however, revealed several areas of concern for the group.

All three women voiced that they had gained weight over the past 6 months. The body mass index (BMI) of two of the three women was greater than 25, whereas the third member’s BMI was borderline. A BMI of 19 to 25 is associated with a low risk to health, whereas the potential for health risks increases with a BMI greater than 25 (Snelling & Stevenson, 1999). The women also revealed that demands on their time kept them from consistentl y making healthy food choices and a lack of motivatio n kept them from exer- cising on a regular basis.

In addition to reduced activity levels, their rest and sleep patterns were also altered. Changes in rest and sleep patterns were attribute d to waking during the night to urinate, stress incontinence , hot flashes, and night sweats. In the physiologi c mode, cognator and regulator processes were, for the most part, maintainin g physica l functioning ; however, the adaptation goals of growth and mastery were identified as areas of concern.

Self-concept mode. The basic need underlyin g the self-concept mode is psycho- logical and spiritua l integrity (Roy & Andrews, 1999). Each group member had a strong and solid moral–ethical–spiritual self. Group members described themselves as being in good overall physica l health and expressed that they liked most aspects of their physical appearance. The areas of greatest concern for the members were their slow and steady weight gain, a prominent abdomen, and the loss of their slim waistlines. When asked what they would change about themselve s if they could, group members echoed, “the size of my tummy.” During the first-level assessment for self-concept, the members also ex- pressed that they would like to be more assertive and include their own feelings and needs when making decisions . Overall, cognator and regulator processes were maintainin g ade-

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quate adaptive response s in the self-concept mode, but body image was identified as an area of concern.

Role function mode. The role function mode emphasizes the need for social integ- rity. According to Roy and Andrews (1999), social integrity involves the desire to know who one is in relation to others. The group members ranged in age from 50 to 54 years old. Developmental tasks for the group members fell within Havighurst’s (as cited in Lefrancois, 1987) middle adulthoo d phase. Tasks specific to this phase and to the group members include d assistin g children in their transitio n from home to world, relating to spouse , maintainin g satisfactory career performance, and adjustin g to the physiologica l changes of middle age. The group members were able to accomplish the routine tasks of daily living and were working on achieving the different developmenta l tasks. All mem- bers were married, with either one or two grown children and no grandchildren . One of the group members was self-employed , whereas the other two members worked full-tim e outside the home. All members were active participant s in their church and had many hob- bies and interests. Group members found their roles at work and home challenging , but satisfyin g and saw their varied roles as a way of expressing themselves. The cognator and regulator processes for the role function mode were judged to be adaptive.

Interdependence mode. The primary focus of the interdependenc e mode is rela- tional integrity or the feeling of security in relationship s (Roy & Andrews, 1999). Interde- pendent relationship s involve the willingnes s and ability to give and receive from others, love, respect, and nurturing (Dunn & Dunn, 1997). The women in the group felt that their husbands and children were the most important people in their lives and stated that they were able to express their love for their family, both verbally and physically . The women stated that they felt valued and loved by their family. The identifie d areas of concern for the group members, however, were feeling that their husbands and children did not under- stand menopause and could not relate to their physica l symptom s or biologica l changes. The women also revealed that older Jamaican women are usually very private individual s and are cautious, sometimes even reluctant, to discuss personal health problems with their family or close friends. The cognator and regulator processes for the interdependenc e mode were judged to be ineffective because group members did not feel supporte d by oth- ers on their journey through menopause.

Second-Level Assessment

Roy and Andrews (1999) wrote, “it is change in the internal and external stimuli that places stress on the coping abilitie s of the human adaptive system” (p. 71). The sec-

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ond-level assessment in the Roy adaptation model involves determining the focal, contex- tual, and residual stimuli influencing behavioral responses.

Behavioral responses for the group were judged to be ineffective in the self-concept mode and the interdependenc e mode. Focal stimuli influencing the self-concept mode and the interdependenc e mode were identifie d as the hormone-related changes of meno- pause and the members’ inability to discuss menopause with family and friends. The rel- evant contextual stimuli included the following: the aging process, poor knowledge base regarding the physiolog y and management of menopause, multiple stressors of middle age, the developmenta l task of dealing with “who I will be and who I have been” (Barnfather, Swain, & Erickson, 1989, p. 177), the stress of fulfillin g multiple family roles, and ethnicity . The residual stimuli identified were cultural beliefs and attitudes to- wards menopause, sexuality, and gender roles.

ANALYSIS

Diagnosis

According to the Roy (Roy & Andrews, 1999) adaptation model, the next step in the nurs- ing process involve s formulating statements or nursing diagnoses to interpret the behav- ioral data and the stimuli influencin g the behavioral responses. The nursing diagnosis is a judgement process made by the nurse (Roy & Andrews, 1999). The first clause of the nursing diagnosi s is derived from first-level assessment data, whereas the second clause is based on second-level assessment data (Piazza et al., 1992). For clarity within the profes- sion and the purposes of this article, the nursing diagnoses were stated using the North American Nursing Diagnosis Association ’s diagnosti c classificatio n system (Johnson , Bulechek, Dochterman, Maas, & Moorhead, 2001). Hence, the analysis of the informa- tion obtaine d during the assessment phase identified the following nursing diagnoses for the group: (a) disturbanc e in body image related to menopause and (b) social isolatio n re- lated to inability to discuss menopause with immediate family and friends.

Goal Setting

Goal setting focuses on the identified ineffective behaviors and clearly outline s behav- ioral outcomes of nursing care that will promote adaptation (Roy & Andrews, 1999). In the Roy adaptation model, the goal statement outlines the adaptive behavior to be ob- served, describes the manner in which the behavior will change, and states the time frame in which the goal will be attained. The goals for this group of Jamaican-Canadia n women were as follows: (a) by the completion of Session 6, each group member will voice an en-

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hanced confidence in her body image, and (b) by the completion of Session 6, each group member will identify one person to whom she can talk freely to about menopause .

Interventions

Once the goals had been established , nursing intervention s were planned that focused on managing the stimuli and promoting adaptation (Piazza et al., 1992). The management of stimuli involve s either altering, increasing, decreasing, removing, or maintainin g focal, contextual , and residual stimuli (Roy & Andrews, 1999). The three group members con- sented to attending weekly group sessions and agreed that I would design and facilitate each session as teaching and leadership skills are fundamenta l roles in my profession as a licensed registered nurse.

Nursing intervention s for the group focused on issues dealing with menopause, the focal stimuli identified as the primary cause of the disturbanc e in body image and so- cial isolation . A detailed presentation on menopause was given by me using colorful pictures. Throughout the presentation , the use of open-ended question s facilitate d the discussio n of the physica l and psychologica l changes that accompany menopause . In- formal brochures and pamphlets were also distribute d to the group members to en- hance teaching and learning. At the end of the presentation , members completed the Menopause Myths and Realities quiz (located on the World Wide Web at http://www.neri.org/html/Healinfo/menoquiz.htm) to assess their knowledge.

In a descriptiv e study of a randomly selected sample of 750 women, aged 45 to 60, 50% of the women reported reading materials as their main source of information on menopause (Kaufert et al., 1998). Similarly, the group members reported that they had obtained the majority of their information about menopause from popular magazines and newsletters in health food stores. The members also stated that health care professional s had provided them with some verbal clarification of issues surroundin g menopause . The purpose of the presentatio n on menopause was to insure that each group member had a basic and accurate understanding of menopause.

Based on the findings of the Kaufert et al. (1998) study, members were asked to pay close attention to and collect information on the portrayal of older women, aging, and menopause in magazines, newspapers, and on television . According to the Roy (Roy & Andrews, 1999) adaptation model, body image refers to “how the body looks to oneself and how one feels about how the body looks and functions ” (p. 388). The media information collected by the group members facilitated discussion s about factors influencin g body image. The group discusse d how there are many coming-of-age televisio n shows and movies, but rela- tively few change-of-life movies. The members, in fact, were unable to name one popula r change-of-life movie. Group members also discusse d how today’s culture worships look- ing and feeling young and fears growing old. The members also explored the power of the media and how the media influenced how they felt about themselves.

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The group members were pleased with the increased attention being given to meno- pause, but were concerned that most of the attention appeared to be directed towards medicalizing menopause. In the Kaufert et al. (1998) study, 53% of the women surveyed believed that menopause should be treated with diet, vitamins, and exercise instead of with hormones. The group members also agreed with this view. In fact, during the first group session, members had stated that they wanted to use the group to find out what oth- ers were doing to deal with the physical symptoms of menopause and to learn about natu- ral remedies to treat menopause.

The physical symptoms of increased urination , stress incontinence , hot flashes, and night sweats were identifie d as contributin g to the disturbanc e in body image for the group members. Alternative therapies to decrease the physical symptoms of menopause and enhance body image were therefore discussed .

Discussion s about alternative herbal remedies focused on phytoestrogens . Weed (1999) wrote that phytoestrogen s are naturally occurring compounds found in certain plants, herbs, and seeds that have a molecular structure similar to that of steriodal estrogens. When Avis et al. (1993) compared the extent to which menopause differed across three populations , it was found that Japanese women reported lower rates of hot flashes than Canadian and American women. Avis et al. hypothesize d that the lower rates of hot flashes in Japanese women may be due to their low fat diet. Diets high in grains, fresh fruits, and vegetable s are high in phytoestrogen s (Weed, 1999). One group member shared that she had been using wild yam cream to treat her symptom s of hot flashes. Wild yam is a phytoestrogen-ric h herb (Weed, 1999). According to Weed, “wild yam creams outsell all other menopausal products and are generally considered to be alternative med- icine’s alternative to prescriptio n estrogen” (p. 274). Other alternative herbal remedies discusse d include d evening primrose and vitamin E, soy products, and ginseng. I empha- sized to the group members that more research is needed on alternative products and that not all alternative herbal remedies have been tested to ensure consistenc y (North Ameri- can Menopause Society, 1999).

To combat the urinary symptom s of menopause, group members were taught how to perform daily pelvic floor exercises called Kegel exercises. Scura and Whipple (1997) wrote that when done correctly, Kegel exercises may reduce the incidence of stress in- continence in 50% to 90% of women within a few months.

To help promote rest and relaxation, stress reduction techniques of deep breathing, stretching , massage, and daily affirmations were discusse d and practiced. Dossey (1995) wrote that in addition to reducing stress, relaxation and daily affirmations can also en- hance a person’s body image.

To round out the group’s knowledge on menopause , the group watched two videos on hormone replacement therapy and discussed the risks and benefits of this modality. Pre- vention of osteoporosi s and heart disease are two of the major reasons given for starting hormone replacement therapy (Weed, 1999). The group, therefore, spent time discussin g these major diseases and each member completed risk factor assessments for osteoporo -

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sis and heart disease. The importanc e of regular exercise, especially to keep members flexible and to help make bones more resistant to breaking, was stressed (Weed, 1999). Along with daily exercise, the importance of a balanced diet, as per Canada’s Food Guide (Health Canada, 1992) and the role dietary intervention s play in weight manage- ment and the reduction of heart disease were discussed .

Rousseau (1998) wrote that there is a progressiv e increase in weight gain at the age of menopause due to the aging process. Menopause is associated with a loss of muscle and an increase in abdomina l fat mass. Perceptions of body image can be threatened with the changes in body shape and function that are brought on by the aging process. To improve body image, the group received instruction s about physica l activity and the health bene- fits of exercise. Exercise enhances weight loss when combined with dietary modificatio n and is one of the best predictors of long-term maintenance of weight loss (Jakicic et al., 1999). With the assistanc e of Canada’s Physical Activity Guide (Health Canada, 1998), group discussion s focused on identifyin g specific ways each member could increase her activity level and the exercises that members could perform to strengthen their abdomi- nal muscles.

Results of the Kaufert et al. (1998) survey showed that 31% of the women interviewed found menopause to be associated with feelings of spirituality . Schaub and Schaub (1999) wrote that spiritualit y is beneficial to clients and encouraged health care profes- sionals to include spiritualit y in their clinical practice. Each group member had a strong moral–ethical–spiritual self and was very receptive to incorporating spiritualit y and reli- gion into the group sessions. To facilitate a discussio n on spirituality , the Spiritual As- sessment and Sources of Spiritua l Support exercises, both by Hopkins, Woods, Kelley, Bentley, and Murphy (1995), were completed. Interestingly , menopause was recognized as a stage in the life cycle as far back as the Biblical era (Choi, 1995). Group members, therefore, identified four postmenopausa l female Bible characters, discussed the strengths of the characters, and shared how each character could serve as a role model for menopausal women. The session on spiritualit y reinforced to the group members that faith can be an important factor in dealing with stress and life changes.

Utian and Boggs (1999) conducted a telephone survey to assess the perceptions of 752 postmenopausa l women regarding their menopause transitio n years. The study found that women were more likely to have discussed menopause with a friend their own age or someone from their own generation (83%) than they were with their mother (53%), with a spouse or partner (61%), or with their daughte r (69%). The group members had not dis- cussed menopause with their own mothers or daughters. Also, discussion s with their hus- bands about menopause had been brief and infrequent. Choi (1995) wrote, “encouraging women to express their personal concerns, expectations , and experiences about meno- pause may assist them in identifyin g and releasing some of their pent-up fears and appre- hension” (p. 61).

In the Massachusetts Women’s Health Study (Avis & McKinlay, 1995), women were asked to describe their feelings about the cessation of menstruation . More than 70% of

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the women chose either “neutral” or “relief” whereas only 3% chose “regret.” When the group members were asked to do the same, all three women described a state of “free- dom.” Guided by the question s and results in the Massachusetts Women’s Health Study, the members expressed their concerns about menopause and observed that they shared symptom s and experiences similar to other women. The group members were encour- aged to call each other outside of group time, to be a source of support to each other, and to pass on the information they learned about menopause to other women.

EVALUATION

Throughout the group sessions , information was shared, feelings explored, ideas ex- changed, and members were given support. According to the Roy (Roy & Andrews, 1999) adaptation model, during the evaluation phase of the nursing process the nurse collabo- rates with the client to assess the effectiveness of the intervention s in achieving the estab- lished behavioral goals. Roy and Andrews wrote that the nurse can conclude that interven- tions are effective when ineffective responses become adaptive or when previousl y adaptive responses remain adaptive.

Two tools to evaluate the effectiveness of the group sessions in assistin g the women to develop adaptive responses towards menopause were developed by me and distribute d at the final session. “Menopause Bingo” (refer to the Appendix) , a card with squares con- taining question s and statements from the various topics discusse d during the six group sessions , was given to each group member to complete. Although it was presented to the group members as a game, Menopause Bingo and the discussion s generated from its use provided insight into the quality of information learned, retained, and applied over the course of the six sessions. The second tool, an evaluation form, provided each group member with an opportunity to rate and comment on the sessions and the group leader.

Based on the results of Menopause Bingo and the evaluation form, it was determined that both group goals were achieved. Each group member voiced an enhanced confi- dence in her body image and was able to name at least one person she could talk freely to about menopause. One hundred percent of the group members rated the group sessions as very satisfyin g and the content as always easy to understand . Group members also rated their knowledge base of menopause as good. When asked what they enjoyed most about the group sessions , members wrote “learning about our bodies” and “sharing knowledge and experiences with each other.” Additional comments recorded on the evaluation form included, “Things that I never talk to anyone about came out in the open” and “These ses- sions need to be shared with other women because of the lack of information out there.”

Menopause is a time of transitio n that results in a variety of physical and psychologi - cal changes for women. The Roy (Roy & Andrews, 1999) adaptation model provided a holisti c approach to assessing and analyzing the menopausal transition. Small groups fa- cilitate d by community health clinical nurse specialist s using the Roy adaptation model

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may provide women with the suppor t and guidanc e needed to cope with the developmen- tal processes of menopause.

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Avis, N. E., Kaufert, P. A., Lock, M., McKinlay, S. M., & Vass, K. (1993). The evolution of menopausal symptoms. Bailliere’s Clinical Endocrinology and Metabolism, 7, 17–32.

Avis, N. E., & McKinlay, S. M. (1995). The Massachusetts women’s health study: An epidemiologic investi- gation of the menopause. Journal of the American Medical Women’s Association, 50, 45–49, 63.

Barnfather, J. S., Swain, M. P., & Erickson, H. C. (1989). Evaluation of two assessment techniques for adapta- tion to stress. Nursing Science Quarterly, 2, 172–182.

Choi, M. W. (1995). The menopausal transition: Change, loss, and adaptation. Holistic Nursing Practice, 9(3), 53–62.

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Kaufert, P., Boggs, P. P., Ettinger, B., Woods, N. F., & Utian, W. H. (1998). Women and menopause: Beliefs, attitudes, and behaviors. The North American menopause society 1997 menopause survey. Menopause, 5, 197–202.

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Schaub, B. G., & Schaub, R. (1999). Spirituality and clinical practice. Alternative Health Practitioner, 5, 145–149.

Scura, K. W., & Whipple, B. (1997). How to provide better care for the postmenopausal women. American Journal of Nursing, 97(4), 36–44.

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Utian, W. H., & Boggs, P. P. (1999). The North American Menopause Society 1998 menopause survey. Part 1: Postmenopausal women’s perceptions about menopause and midlife. Menopause, 6, 122–128.

Weed, S. S. (1999). Menopause and beyond: The wise woman way. Journal of Nurse-Midwifery, 44, 267–279.

APPENDIX

Menopause Bingo

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