What's Next for Me? Developing an 18-Month Structured Pathway to Increase New Nurse Retention.

Because of increasing RN turnover rates on a neuroscience unit in a large teaching hospital, unit nurse leaders created a staff retention quality improvement initiative. The initiative offered a structured pathway for professional development milestones in a nurse's 1st 18 months of employment. As a consequence of their work, the unit experienced an 82% decrease in the number of RNs who left their job on the unit in the 1st year of implementation.

'Wading through treacle': quality improvement lessons from the frontline.

In a time of financial uncertainty and structural reform, the National Health Service (NHS) in England needs clinical leadership to help improve the quality of patient care. Increasingly, leadership development is being targeted at doctors in postgraduate training to help prepare them for their future leadership roles as consultants and general practitioners. However, there is a risk that we are missing an opportunity here by failing to recognise the role that doctors in training can play now, during their training. As our frontline clinicians they have a unique view of the health service and the inefficiencies therein. The London Deanery has been running an educational programme called Beyond Audit to provide doctors in training with quality improvement skills. During this programme we have been given a unique insight into NHS systems as viewed by junior doctors. They have identified a wide range of small system problems that, when combined, result in large-scale inefficiency and prevent the delivery of high quality patient care. These problems they identify have implications for cost, efficiency, patient safety, team-working and patient experience. Any attempt to improve the quality of care delivered in the NHS needs to look at the system from the point of view of those delivering the care, including our doctors in postgraduate training. By empowering them to make improvements to the systems that they see, there is the potential to make significant improvement in the quality of patient care that they deliver.

The muscle transcription factor MyoD promotes osteoblast differentiation by stimulation of the Osterix promoter.

Transcription factors regulate tissue-specific differentiation of pluripotent mesenchyme to osteoblast (OB), myoblast (MB), and other lineages. Osterix (Osx) is an essential transcription factor for bone development because knockout results in lack of a mineralized skeleton. The proximal Osx promoter contains numerous binding sequences for MyoD and 14 repeats of a binding sequence for Myf5. These basic helix-loop-helix (bHLH) transcription factors have a critical role in MB differentiation and muscle development. We tested the hypothesis that bHLH transcription factors also support OB differentiation through regulation of Osx. Transfection of a MyoD expression vector into two primitive mesenchymal cell lines, C3H/10T1/2 and C2C12, stimulated a 1.2-kb Osx promoter-luciferase reporter 70-fold. Myf5 stimulated the Osx promoter 6-fold. Deletion analysis of the promoter revealed that one of three proximal bHLH sites is essential for MyoD activity. The Myf5 repeat conferred 60% of Myf5 activity with additional upstream sequence required for full activity. MyoD bound the active bHLH sequence and its 3'-flanking region, as shown by EMSA and chromatin immunoprecipitation assays. Real-time PCR revealed that primitive C2C12 and C3H/10T1/2 cells, pre-osteoblastic MC3T3 cells, and undifferentiated primary marrow stromal cells express the muscle transcription factors. C2C12 cells, which differentiate to MB spontaneously and form myotubules, were treated with bone morphogenetic protein 2 (BMP-2) to induce OB differentiation. BMP-2 stimulated expression of Osx and the differentiation marker alkaline phosphatase and blocked myotubule development. BMP-2 suppressed the muscle transcription factor myogenin, but expression of MyoD and Myf5 persisted. Silencing of MyoD inhibited BMP-2 stimulation of Osx and blocked the later appearance of bone alkaline phosphatase. MyoD support of Osx transcription contributes to early OB differentiation.