Legislating Nurse Staffing: Projected Impact on Hospital Economics, Process Flow, and Hospital-Associated Infections in Montana.

OBJECTIVE: The aim of this study was to project the impact of legislated nurse staffing ratios on patient-, staff-, and system-level outcomes for Prospective Payment System (PPS) hospitals in Montana. BACKGROUND: In 2023, House Bill 568 was introduced in Montana focused on legislating hospital safe nursing standards. METHODS: A quantitative design was used for a convenience sample of Montana PPS hospitals. Data were gathered through a newly developed survey and from other publicly available sources for the years 2018 to 2022. Independent t tests were conducted when appropriate with the significance threshold set at 0.05. RESULTS: Projections indicate no significant change in patient outcome metrics accompanied by increases in labor requirements, slower emergency department throughput times, and decreases in hospital operating margins. CONCLUSIONS: In Montana, legislating nurse staffing ratios would have downstream implications inconsistent with the intended impact on patient safety, emphasizing the complexity of variables within and external to the healthcare system that drive patient-, staff-, and system-level outcomes.

A Roadmap to a Comprehensive Evaluation of a Clinical Ladder Program.

Clinical ladder programs were designed to support nurse retention and professional development. Hospital systems are vigorously working to recover from the critical staffing shortages exacerbated by the pandemic. The Centers for Disease Control and Prevention framework for program evaluation was utilized to assess a hospital professional nurse clinical ladder. These findings suggest favorable outcomes in commitment to stay and professional development. This evaluation can serve as a potential resource for organizations to evaluate and enhance programs to support nurse retention.

Behavioral Crisis Management: A Quality Improvement Pilot for Improving Teamwork in a Primary Care Pediatric Setting.

INTRODUCTION: Children with behavioral escalations in the primary care office may pose safety risks to themselves and others. Interprofessional teams utilizing crisis resource management (CRM) skills more successfully manage behavioral crises. The purpose of this quality improvement (QI) pilot project was to improve team performance during a behavioral crisis in pediatric primary care, as well as evaluate learner satisfaction with the curriculum. METHOD: We implemented an evidence-based curriculum using simulation and didactic techniques in primary care offices within a pediatric network. Using a one group pre-post design, we evaluated roles, communication, and patient-centered care with the KidSIM Team Performance Scale. Utilizing a post intervention survey, learner feedback was elicited regarding learning environment, facilitators and barriers to learning, skill of facilitator, and usability and applicability of content. FINDINGS: 101 interprofessional participants attended one of eight educational sessions. KidSIM Team Performance Scale results demonstrated statistically significant improved total team performance in a simulated behavioral crisis (Z = -2.52, p = 0.012). Post simulation evaluation demonstrated positive feedback about the program, content and facilitators. DISCUSSION: This pilot QI project demonstrated that a curriculum using behavioral simulation scenarios and CRM principles can improve teamwork in an interprofessional primary care office. Additionally, participants overwhelmingly indicated satisfaction with the curriculum. APPLICATION TO PRACTICE: Ensuring staff have the appropriate skills to manage behavioral health crises facilitates safer and more effective patient care, enhances patient-centered care and solidifies a positive staff approach in the pediatric ambulatory setting.

Lessons Learned from the Studies of Roots Shaded from Direct Root Illumination.

The root is the below-ground organ of a plant, and it has evolved multiple signaling pathways that allow adaptation of architecture, growth rate, and direction to an ever-changing environment. Roots grow along the gravitropic vector towards beneficial areas in the soil to provide the plant with proper nutrients to ensure its survival and productivity. In addition, roots have developed escape mechanisms to avoid adverse environments, which include direct illumination. Standard laboratory growth conditions for basic research of plant development and stress adaptation include growing seedlings in Petri dishes on medium with roots exposed to light. Several studies have shown that direct illumination of roots alters their morphology, cellular and biochemical responses, which results in reduced nutrient uptake and adaptability upon additive stress stimuli. In this review, we summarize recent methods that allow the study of shaded roots under controlled laboratory conditions and discuss the observed changes in the results depending on the root illumination status.

Assessment of electrooxidation as pre- and post-treatments for improving anaerobic digestion and stabilisation of waste activated sludge.

This study evaluates the effects of electro-oxidation as a means for enhancing sludge stabilisation. Boron-doped diamond electrodes were used to treat waste activated sludge and digestate under different operating parameters (current density, conductivity, pH, and time). Electro-oxidation runs affected the solubilisation of organic matter, which seemed to improve anaerobic digestion and dewaterability characteristics. Among the tested parameters, pre-treating sludge via electro-oxidation under alkaline conditions (Treatment T5) resulted in the highest increase in soluble organic material compared to that in the control, with total organic carbon (TOC) and soluble chemical oxygen demand (COD) values of 2753 and 7819 mg L-1, respectively (control TOC and COD values were 385 and 1073 mg L-1). This pretreatment also achieved a high hydrolysis rate (higher concentration in volatile fatty acids) with a concomitant increase in methane yield (approximately 18%). On the other hand, the application of electro-oxidation as a post-treatment for improving digestate dewaterability resulted in noticeable changes in the release of water during drying due to protein and aliphatic matrix modification of the sample.

Components of the Magnet® model provide structure for the future vision of nurse managers' work: A qualitative perspective of nurse managers.

AIM: To describe nurse managers' views of their work in the future. BACKGROUND: Ongoing reformation of health care organisations includes profound changes to nurse managers' work practices. METHOD: A qualitative approach was applied to elicit views of nurse managers (n = 133) from eight Finnish specialized medical care hospitals through one open-ended question about their future work in November 2019. The acquired data were subjected to inductive thematic content analysis. RESULTS: Four themes were identified in the nurse managers' responses, indicating that they anticipated: 1) a shift from hierarchical leadership to shared governance, 2) an increasing focus on proactive and systematic work, 3) development of evidence-based practices and 4) improvement in the attractiveness and effectiveness of the organisation. CONCLUSIONS: Nurse managers envisage their future work will follow the transformational leadership model. Shared governance and multidisciplinary team leading, with a stronger focus on proactive strategic planning will extend their power to influence decision-making. Administrative supporting systems will free more time from their daily routine work for interactions with staff. IMPLICATIONS FOR NURSING MANAGEMENT: Clarification of the managers' job description along with administrative support systems is anticipated to strengthen leadership, facilitate management, enhance decision-making and increase the attractiveness and effectiveness of both health care organisations and nurse managers' work.

Confronting compassion fatigue in oncology nurses.

Oncology nurses are at increased risk for compassion fatigue compared with those in other specialties. This article describes a quality improvement project to create self-compassion tool kits by incorporating the input and opinions of the frontline staff.

Arabidopsis thaliana plants lacking the ARP2/3 complex show defects in cell wall assembly and auxin distribution.

Background and Aim: The cytoskeleton plays an important role in the synthesis of plant cell walls. Both microtubules and actin cytoskeleton are known to be involved in the morphogenesis of plant cells through their role in cell wall building. The role of ARP2/3-nucleated actin cytoskeleton in the morphogenesis of cotyledon pavement cells has been described before. Seedlings of Arabidopsis mutants lacking a functional ARP2/3 complex display specific cell wall-associated defects. Methods: In three independent Arabidopsis mutant lines lacking subunits of the ARP2/3 complex, phenotypes associated with the loss of the complex were analysed throughout plant development. Organ size and anatomy, cell wall composition, and auxin distribution were investigated. Key Results: ARP2/3-related phenotype is associated with changes in cell wall composition, and the phenotype is manifested especially in mature tissues. Cell walls of mature plants contain less cellulose and a higher amount of homogalacturonan, and display changes in cell wall lignification. Vascular bundles of mutant inflorescence stems show a changed pattern of AUX1-YFP expression. Plants lacking a functional ARP2/3 complex have decreased basipetal auxin transport. Conclusions: The results suggest that the ARP2/3 complex has a morphogenetic function related to cell wall synthesis and auxin transport.

Creation of an Adult Observation Unit: Improving Outcomes.

A growing segment of patients in hospitals are considered outpatients, classified as observation. These patients neither have the severity of illness nor the intensity of service to qualify as inpatients, yet are not well enough to be discharged. Hospitals have created observation units to address the clinical needs of this growing patient type to provide care in the right setting by managing emergency department throughput and utilizing the most efficient staffing resources. This article describes the change processes and improvements in quality, length of stay, and patient satisfaction, which occurred following the implementation of an adult observation unit.

Improving the Use of Evidence-Based Practice and Research Utilization Through the Identification of Barriers to Implementation in a Critical Access Hospital.

OBJECTIVE: This study explored the relationship between perceived barriers to research use and the implementation of evidence-based practice (EBP) among rural hospital nurses. BACKGROUND: The Institute of Medicine recommends that 90% of clinical decisions be evidence based by 2020. METHODS: This descriptive, quality improvement study used a convenience sampling of registered nurses (RNs). Participants completed multiple questionnaires. RESULTS: Overall the attitude toward EBP was positive. Nurses recognize the importance to their practice but identified a lack of educational preparation regarding the process of research utilization. CONCLUSION: Providing education on research process and supportive monitoring during implementation may increase compliance with EBP initiatives.

The Effects of Implementing a Patient Acuity Tool on Nurse Satisfaction in a Pulmonary Medicine Unit.

In response to nurses' concerns of equity and satisfaction with patient assignments in a pulmonary medicine unit, a Patient Acuity Tool (PAT) was implemented. The impact of the PAT on nurse satisfaction and perceived equity of patient assignments was measured using a pre-/postsurvey design. Findings of the investigation indicate that a PAT supports nurse satisfaction and equity. In addition, qualitative data suggested that the PAT improved perceived professional autonomy and nurse-to-nurse communication.

Beyond Magnet® Designation: Perspectives From Nurse Managers on Factors of Sustainability and High-Performance Programming.

OBJECTIVE: The aim of this study was to identify patterns of high-performing behaviors and nurse manager perceptions of the factors of Magnet® sustainability at a multidesignated Magnet organization. BACKGROUND: The Magnet program recognizes exemplary professional nursing practice and is challenging to achieve and sustain. Only 10% (n = 42) of Magnet hospitals sustained designation for 12 years or longer. This study explored the perspectives of Magnet nurse managers regarding high-performing teams and the sustainability of Magnet designation. METHODS: A qualitative study of nurse managers was conducted at 1 multidesignated Magnet organization (n = 13). Interview responses were analyzed using pattern recognition of Magnet model domains and characteristics of high-performing teams and then related to factors of Magnet sustainability. RESULTS: Transformational leadership is both an essential factor for sustainability and a potential barrier to sustainability of Magnet designation. CONCLUSIONS: Transformational nursing leaders lead high-performing teams and should be in place at all levels as an essential factor in sustaining Magnet redesignation.

Impact of Magnet Culture in Maintaining Quality Outcomes During Periods of Organizational Transition.

Organizational transition presents substantial risk to maintaining quality outcomes. The leadership style and culture present during periods of change and transition empower the frontline staff to react quickly and identify opportunities. The culture of Magnet develops the skill set that enables staff to be leaders in problem solving and identifying creative care delivery approaches. Objectives of this study were to analyze the impact of organizational transition on patient and staff satisfaction, quality, and safety in a Magnet-designated hospital and determine key factors contributing to these outcomes.

A Quality Improvement Project to Increase Compliance With a Facility Protocol on Surgical Antimicrobial Prophylaxis.

Surgical site infections (SSIs) contribute to negative outcomes for patients and health care organizations. Compliance with clinical practice guidelines likely can help prevent SSIs. An interdisciplinary team at a regional referral center in Michigan sought to reduce SSIs by improving compliance with the facility's preoperative antibiotic selection, dosing, timing, and redosing protocol. The interventions for the quality improvement project included adding the preprocedural antibiotics and doses to the master OR schedule; holding an education session for all preoperative nurses, intraoperative nurses, and anesthesia professionals; and posting a reference guide in the preoperative and intraoperative areas. Compliance with the facility's protocol for antibiotic selection, dosing, and timing significantly improved. However, SSI rates and compliance with redosing recommendations did not change significantly. The team decided to add the antibiotic order information to the master OR schedule permanently. The team plans to consider providing education sessions on administering preprocedural antibiotics outside the OR.

Integrative Multi-Omics Analysis for Etiology Classification and Biomarker Discovery in Stroke: Advancing towards Precision Medicine.

Recent advancements in high-throughput omics technologies have opened new avenues for investigating stroke at the molecular level and elucidating the intricate interactions among various molecular components. We present a novel approach for multi-omics data integration on knowledge graphs and have applied it to a stroke etiology classification task of 30 stroke patients through the integrative analysis of DNA methylation and mRNA, miRNA, and circRNA. This approach has demonstrated promising performance as compared to other existing single technology approaches.

Effect of walnut consumption on neuropsychological development in healthy adolescents: a multi-school randomised controlled trial.

Background: Omega-3 fatty acids are critical for neuropsychological functioning. Adolescence is increasingly believed to entail brain vulnerability to dietary intake. The potential benefit on adolescent neurodevelopment of consuming walnuts, a source of omega-3 alpha-linolenic acid (ALA), remains unclear. Methods: We conducted a 6-month multi-school-based randomised controlled nutrition intervention trial to assess whether walnut consumption has beneficial effects on the neuropsychological and behavioural development of adolescents. The study took place between 04/01/2016 and 06/30/2017 in twelve different high schools in Barcelona, Spain (ClinicalTrials.gov Identifier: NCT02590848). A total of 771 healthy teenagers aged 11-16 years were randomised into two equal groups (intervention or control). The intervention group received 30 g/day of raw walnut kernels to be incorporated into their diet for 6 months. Multiple primary endpoints concerning neuropsychological (working memory, attention, fluid intelligence, and executive function) and behavioural (socio-emotional and attention deficit hyperactivity disorder [ADHD] symptoms) development were assessed at baseline and after intervention. Red blood cell (RBC) ALA status was determined at baseline and 6 months as a measure of compliance. Main analyses were based on intention-to-treat using a linear mixed-effects model. A per-protocol effect of the intervention was analysed using inverse-probability weighting to account for post-randomisation prognostic factors (including adherence) using generalised estimating equations. Findings: In intention-to-treat analyses, at 6 months there were no statistically significant changes between the intervention and control groups for all primary endpoints. RBC ALA (%) significantly increased only in the intervention group, coefficient = 0.04 (95% Confidence Interval (CI) = 0.03, 0.06; p < 0.0001). The per-protocol (adherence-adjusted) effect on improvement in attention score (hit reaction time variability) was -11.26 ms (95% CI = -19.92, -2.60; p = 0.011) for the intervention group as compared to the control group, improvement in fluid intelligence score was 1.78 (95% CI = 0.90, 2.67; p < 0.0001), and reduction of ADHD symptom score was -2.18 (95% CI = -3.70, -0.67; p = 0.0050). Interpretation: Our study suggested that being prescribed eating walnuts for 6 months did not improve the neuropsychological function of healthy adolescents. However, improved sustained attention, fluid intelligence, and ADHD symptoms were observed in participants who better complied with the walnut intervention. This study provides a foundation for further clinical and epidemiological research on the effect of walnuts and ALA on neurodevelopment in adolescents. Funding: This study was supported by Instituto de Salud Carlos III through the projects 'CP14/00108, PI16/00261, PI21/00266' (co-funded by European Union Regional Development Fund 'A way to make Europe'). The California Walnut Commission (CWC) has given support by supplying the walnuts for free for the Walnuts Smart Snack Dietary Intervention Trial.

ARP2/3 complex associates with peroxisomes to participate in pexophagy in plants.

Actin-related protein (ARP2/3) complex is a heteroheptameric protein complex, evolutionary conserved in all eukaryotic organisms. Its conserved role is based on the induction of actin polymerization at the interface between membranes and the cytoplasm. Plant ARP2/3 has been reported to participate in actin reorganization at the plasma membrane during polarized growth of trichomes and at the plasma membrane-endoplasmic reticulum contact sites. Here we demonstrate that individual plant subunits of ARP2/3 fused to fluorescent proteins form motile spot-like structures in the cytoplasm that are associated with peroxisomes in Arabidopsis and tobacco. ARP2/3 is found at the peroxisome periphery and contains the assembled ARP2/3 complex and the WAVE/SCAR complex subunit NAP1. This ARP2/3-positive peroxisomal domain colocalizes with the autophagosome and, under conditions that affect the autophagy, colocalization between ARP2/3 and the autophagosome increases. ARP2/3 subunits co-immunoprecipitate with ATG8f and peroxisome-associated ARP2/3 interact in vivo with the ATG8f marker. Since mutants lacking functional ARP2/3 complex have more peroxisomes than wild type, we suggest that ARP2/3 has a novel role in the process of peroxisome degradation by autophagy, called pexophagy.

Throttling Growth Speed: Evaluation of aux1-7 Root Growth Profile by Combining D-Root system and Root Penetration Assay.

Directional root growth control is crucial for plant fitness. The degree of root growth deviation depends on several factors, whereby exogenous growth conditions have a profound impact. The perception of mechanical impedance by wild-type roots results in the modulation of root growth traits, and it is known that gravitropic stimulus influences distinct root movement patterns in concert with mechanoadaptation. Mutants with reduced shootward auxin transport are described as being numb towards mechanostimulus and gravistimulus, whereby different growth conditions on agar-supplemented medium have a profound effect on how much directional root growth and root movement patterns differ between wild types and mutants. To reduce the impact of unilateral mechanostimulus on roots grown along agar-supplemented medium, we compared the root movement of Col-0 and auxin resistant 1-7 in a root penetration assay to test how both lines adjust the growth patterns of evenly mechanostimulated roots. We combined the assay with the D-root system to reduce light-induced growth deviation. Moreover, the impact of sucrose supplementation in the growth medium was investigated because exogenous sugar enhances root growth deviation in the vertical direction. Overall, we observed a more regular growth pattern for Col-0 but evaluated a higher level of skewing of aux1-7 compared to the wild type than known from published data. Finally, the tracking of the growth rate of the gravistimulated roots revealed that Col-0 has a throttling elongation rate during the bending process, but aux1-7 does not.

CRISPR-Cas9 Arabidopsis mutants of genes for ARPC1 and ARPC3 subunits of ARP2/3 complex reveal differential roles of complex subunits.

Protein complex Arp2/3 has a conserved role in the nucleation of branched actin filaments. It is constituted of seven subunits, including actin-like subunits ARP2 and ARP3 plus five other subunits called Arp2/3 Complex Component 1 to 5, which are not related to actin. Knock-out plant mutants lacking individual plant ARP2/3 subunits have a typical phenotype of distorted trichomes, altered pavement cells shape and defects in cell adhesion. While knock-out mutant Arabidopsis plants for most ARP2/3 subunits have been characterized before, Arabidopsis plant mutants missing ARPC1 and ARPC3 subunits have not yet been described. Using CRISPR/Cas9, we generated knock-out mutants lacking ARPC1 and ARPC3 subunits. We confirmed that the loss of ARPC1 subunits results in the typical ARP2/3 mutant phenotype. However, the mutants lacking ARPC3 subunits resulted in plants with surprisingly different phenotypes. Our results suggest that plant ARP2/3 complex function in trichome shaping does not require ARPC3 subunit, while the fully assembled complex is necessary for the establishment of correct cell adhesion in the epidermis.