Evaluating the Clinical Practice Model's Strengths and Improvement Opportunities Using the Professional Practice Framework Assessment Survey: One Integrated Healthcare System's Experience.

OBJECTIVES: The aims of this study are (1) to describe the division, organizational strengths, and improvement opportunities of self-reported behaviors indicative of the multidimensional construct of professional practice and (2) to understand demographic characteristics that contributed to these strengths and improvement opportunities. BACKGROUND: Prior to implementing a system-wide interdisciplinary shared governance structure, ProHealth Care measured staff attitudes toward the multidimensional construct of professional practice as proposed within the Clinical Practice Model framework using the Professional Practice Framework Assessment Survey (PPFA-S). METHODS: Clinical and support staff were invited to share their views toward professional practice using the previously validated, reliable tool, the PPFA-S. RESULTS: Partnering relationships, scope of practice, and shared purpose were strengths. Strategies were initiated to strengthen networking councils, integrated competency, evidence-based practice, transformative capacity, and clinical tools. CONCLUSIONS: The survey identified professional practice strengths and improvement opportunities across the organization as well as factors contributing to these strengths and opportunities. These findings were useful to help guide system integration.

Predictors of Caring in the Context of Relationship-Based Care.

The caring connection between patients and health-care staff members is important to both patients and staff. This connection is amplified in organizations implementing Relationship-Based Care (RBC), a patient care delivery model that has relationships with self and others as its central concept. A secondary analysis of data from 542 health-care workers in a health-care system in the northeastern United States was performed to identify a profile of staff factors that predict a caring connection as perceived by staff. Specifically, staff self-care, clarity (of self, role, and system), dimensions of job satisfaction, and demographics were examined in relationship to caring for patients. The study demonstrated that constructs within RBC do relate to the creation of a caring connection between health-care staff members and patients, including caring for self, having a direct relationship with the patient using concepts of Primary Nursing, clarity of role, and being a direct care provider.

Content validity, face validity and internal consistency of the Slovene version of Caring Factor Survey for care providers, caring for co-workers and caring of managers.

BACKGROUND: Caring relationships are important for developing a caring culture. It is important that care provider's relationships with patients, co-workers and managers are caring relationships. However, in the Slovene language, there is a lack of psychometrically sound instruments to measure these caring relationships. AIM: To explore the psychometric properties of the Slovenian version of the Caring Factor Survey (CFS) for care providers, the care given by co-workers and managers as judged by the providers, by evaluating its content validity, face validity and internal consistency. METHODS: In the process of our instrument, we used translation and back translation and validation based on experts' agreement. Content validity was quantified by the content validity index (CVI) and a modified Cohen's kappa index. Face validity was evaluated by ten nurses who reviewed the instruments. In the process of psychometric testing based on survey data, we used a cross-sectional research design with a convenience sample of 91 caregivers working in internal or surgical wards in two health care institutions. Cronbach's alpha and corrected item-total correlations were used to test internal consistency. RESULTS: All items in all three versions of the CFS had a CVI score higher than 0.78 and excellent modified Cohen's kappa index, showing excellent content validity. The average content validity indices were 0.990, 0.975 and 0.963. The face validity was good with no major remarks given. Cronbach's alpha was 0.941, 0.962 and 0.970. The item-total correlations reached a criterion of 0.2 < r < 0.3 for all items. CONCLUSION: All three versions of the CFS showed an acceptable content validity, face validity and internal consistency; however, due to some methodological shortcomings, results should be interpreted with caution. Further psychometric testing is needed.

The Impact of the Primary Nursing Model on Cultural Improvement: A Mixed-Method Study.

Evaluating the implementation of care models such as Primary Nursing requires assessment of both short-term and long-term outcomes. In a hospital in Piemonte, Italy, a mixedmethod time-series study was conducted to assess if and how the organizational culture of nurses changed in relation to the implementation of a new organizational model of care. Instruments used included the Condition of Work Effectiveness Questionnaire (CWEQ II) and an investigator-developed questionnaire to evaluate perceptions of dimensions consistent with Primary Nursing. Results showed a significant culture change over time related to the implementation of Primary Nursing, mainly in terms of nurses' understanding of their professional role specifications. In addition, the results supported a relationship between being involved in the project implementation and the procedural and cultural approach adopted.

The mechanism of a ligand-promoted C(sp3)-H activation and arylation reaction via palladium catalysis: theoretical demonstration of a Pd(II)/Pd(IV) redox manifold.

Density functional theory (DFT) computations (BP86 and M06-L) have been utilized to elucidate the detailed mechanism of a palladium-catalyzed reaction involving pyridine-type nitrogen-donor ligands that significantly expands the scope of C(sp(3))-H activation and arylation. The reaction begins with precatalyst initiation, followed by substrate binding to the Pd(II) center through an amidate auxiliary, which directs the ensuing bicarbonate-assisted C(sp(3))-H bond activation producing five-membered-ring cyclopalladate(II) intermediates. These Pd(II) complexes further undergo oxidative addition with iodobenzene to form Pd(IV) complexes, which proceed by reductive C-C elimination/coupling to give final products of arylation. The base-assisted C(sp(3))-H bond cleavage is found to be the rate-determining step, which involves hydrogen bond interactions. The mechanism unravels the intimate involvement of the added 2-picoline ligand in every phase of the reaction, explains the isolation of the cyclopalladate intermediates, agrees with the observed kinetic hydrogen isotope effect, and demonstrates the Pd(II)/Pd(IV) redox manifold.

Using the Profile of Caring: Measuring Nurses' Caring for Self and Caring by Their Unit Manager.

The Caring Factor Survey - Caring for Self and the Caring Factor Survey - Caring of the Manager are 10-item instruments used to assess nurses' self-report of caring for self and nurses' perception of caring as demonstrated by their unit or department manager, respectively. Each 10-item survey assesses the 10 processes of caring described within Watson's Theory of Transpersonal Caring. Structural equation modeling was used to assess for item mis-specification (for items that did not belong among the 10 items) among the responses from 1,650 nursing staff from six countries. Three types of invariance testing were then used to assess whether the same items were equally relevant across all participating countries. Results revealed that each survey had six items specified to measure that type of caring relationship (i.e., caring for self and caring by the manager), including five items that were the same in both surveys and one unique item in each. Final items were found to be equally relevant across all participating countries. In a global model, both caring relationships were found to relate to nurses' clarity about their role and about the system in which they work, as well as their job satisfaction. Implications for a global study of caring and for impacts on work environments are discussed.

The Profile of Caring: An Internationally Tested Model to Assess and Support Nurses During Pandemic.

The psychological impact of the COVID-19 pandemic on nurses, and subsequent increases in turnover, have been extensively documented. This article examines a profile of nurses which included (1) the degree to which direct-care nurses are caring for themselves, (2) the degree to which their manager acts in a caring way, (3) the degree to which nurses have clarity about their professional role and about how the system works, and (4) the degree to which nurses are satisfied with essential social and technical dimensions of their jobs, to help understand how some of the critical internal states and working relationships of nurses fit together as a model. To test the model, authors used structural equation modeling with a 35-item measurement tool in three countries (Russia, Serbia, and Turkey; n = 984), replicating a recent 8-country study. Results revealed a good model fit, similar to the original study, despite statistically significant differences in mean scores between the countries studied. Good model fit with a second group of countries, despite differences in mean scores, suggests that results from both studies can be used for a global conversation about how caring, clarity, and job satisfaction in nursing relate to one another. These results provide evidence that health facilities should study variables such as caring for self, caring by the unit or department manager, clarity of role and system, and job satisfaction to learn about, recover, and monitor nurses' health and experience of work as they emerge from the pandemic.

Measuring caring--the next frontier in understanding workforce performance and patient outcomes.

Caring is not generally considered in structured and scientific analysis of situations. But this may be a mistake. Caring likely has a return on investment that surpasses all other technology, pharmacotherapy, or system that has been developed to date for health care. As the puzzle of caring as an intervention of healing continues to come together, the outcomes of care for self and others will become clear. It is apparent by the number of studies generated by just one group, the Caring International Research Collaborative, there is a shared belief caring is healing and has a potential for return on investment that has yet to be realized.

Measuring the Level of Reflective Ability of Predoctoral Dental Students: Early Outcomes in an e-Portfolio Reflection.

Learning to evaluate one's own skills through reflection and self-assessment prepares dental graduates for successfully navigating an ever-changing work environment throughout their careers, but the search continues for the most effective teaching and assessment strategies to develop students' skills in these areas. Beginning with the Class of 2017, the University of Missouri-Kansas City School of Dentistry adopted e-portfolios as a programmatic (four-year) global assessment measure in the predoctoral dental program, in large part to encourage the development of reflection. The aim of this study was twofold: to examine interrater reliability among raters when scoring reflective writing using a validated measure of reflection skill and to analyze students' level of reflective ability as fourth-year dental students. Reflections of all 102 students were independently evaluated by the three investigators using a grading rubric based on Bain's 5 Rs (reporting, responding, relating, reasoning/deconstructing, reconstructing). Intra-class correlation was used to assess interrater reliability among the three raters, resulting in a good range for agreement (ICC=0.67; 95% CI 0.54, 0.77). The results showed that the majority (70%) of the global reflections were rated at Level 2 (responding) and Level 3 (relating). Approximately 15% of the global reflections reached Level 4 (reasoning/deconstructing), and only one was rated at the highest level (Level 5, reconstructing). This study confirmed that reflection and reflective writing were difficult for students to accomplish. As a result, curricular enhancements at this school have been implemented that involve both faculty and student development. Ongoing evaluation is required to determine if those changes result in higher levels of reflective ability. The positive outcomes of reflection and writing warrant continued examination in how to improve this educational strategy across the curriculum.

Equivalent uniform dose, D(90), and V(100) correlation with biochemical control after low-dose-rate prostate brachytherapy for clinically low-risk prostate cancer.

PURPOSE: To assess the correlation of postimplant dosimetric quantifiers with biochemical control of prostate cancer after low-dose-rate brachytherapy. MATERIALS AND METHODS: Generalized equivalent uniform dose (EUD), dose in Gy to 90% of the prostate gland (D(90)), and percentage of the prostate receiving 100% of the prescribed dose (V(100)) were calculated from the postimplant dose-volume histogram (DVH) for 140 patients undergoing low-dose-rate prostate brachytherapy (LDRPB) monotherapy from 1997 to 2003 at Duke University and the Durham VA Medical Center. Biochemical recurrence was defined according to the American Society for Therapeutic Radiology and Oncology consensus definition. RESULTS: Median followup after LDRPB was 50 months. There was a 7% biochemical recurrence rate (10/140) at last clinical followup. The median EUD was 167 Gy (range, 41-245). The median D(90) was 139 Gy (range, 45-203). The median V(100) was 88% (range, 44-100). The overall 5-year biochemical recurrence-free survival (bRFS) was 94.2%. The 5-year bRFS was 100% for EUD> or =167 Gy and 89.4% for EUD <167 Gy (p=0.008); 100% for D(90) > or =140 Gy and 90.4% for D(90) <140 Gy (p=0.020); 100% for V(100) > or =88%; and 90.3% for V(100) <88% (p=0.017). There was no statistically significant correlation between any of these factors and overall survival. CONCLUSIONS: In our series of 140 patients with low-risk prostate cancer treated with LDRPB alone, we observed a statistically significant correlation between EUD, D(90), and V(100) and bRFS. The generalized EUD, a calculated value that incorporates the entire prostate DVH, appears to be at least as well correlated with bRFS as D(90) or V(100), and may more completely represent the totality of the dose distribution.

Current State of Test Development, Administration, and Analysis: A Study of Faculty Practices.

Developing valid and reliable test items is a critical skill for nursing faculty. This research analyzed the test item writing practice of 674 nursing faculty. Relationships between faculty characteristics and their test item writing practices were analyzed. Findings reveal variability in practice and a gap in implementation of evidence-based standards when developing and evaluating teacher-made examinations.

Duodenal adenocarcinoma: patterns of failure after resection and the role of chemoradiotherapy.

PURPOSE: To report patterns of disease recurrence after resection of adenocarcinoma of the duodenum and compare outcomes between patients undergoing surgery only vs. surgery with concurrent chemotherapy and radiation therapy (CT-RT). METHODS AND MATERIALS: This was a retrospective analysis of all patients undergoing potentially curative therapy for adenocarcinoma of the duodenum at Duke University Medical Center and affiliated hospitals between 1975 and 2005. Overall survival (OS), disease-free survival (DFS), and local control (LC) were estimated using the Kaplan-Meier method. Univariate regression analysis evaluated the effect of CT-RT on clinical endpoints. RESULTS: Thirty-two patients were identified (23 M, 9 F). Median age was 60 years (range, 32-77 years). Surgery alone was performed in 16 patients. An additional 16 patients received either preoperative (n = 11) or postoperative (n = 5) CT-RT. Median RT dose was 50.4 Gy (range, 12.6-54 Gy). All patients treated with RT also received concurrent 5-fluorouracil-based CT. Two patients treated preoperatively had a pathologic complete response (18%), and none had involved lymph nodes at resection. Five-year OS, DFS, and LC for the entire group were 48%, 47%, and 55%, respectively. Five-year survival did not differ between patients receiving CT-RT vs. surgery alone (57% vs. 44%, p = 0.42). However, in patients undergoing R0 resection, CT-RT appeared to improve OS (5-year 83% vs. 53%, p = 0.07). CONCLUSIONS: Local failure after surgery alone is high. Given the patterns of relapse with surgery alone and favorable outcomes in patients undergoing complete resection with CT-RT, the use of CT-RT in selected patients should be considered.

Decompression sickness in a swine model: isobaric denitrogenation and perfluorocarbon at depth.

INTRODUCTION: Disabled submarine survivors could achieve inert gas tissue saturation likely to cause severe decompression sickness (DCS) on surfacing. This risk increases with time and depth of exposure. Methods to reduce DCS risk and severity are needed specifically for such an operational scenario. METHODS: Yorkshire swine (16.2-26.6 kg) fitted with an external jugular catheter were compressed to 5 ATA for 22 h. They then received an enriched breathing mix of 44% N2 and 56% O2, and an infusion of either saline or a perfluorocarbon (PFC) emulsion, and were observed for 2 h before surfacing without decompression stops. Controls were surfaced after 22 h saturation at 5 ATA. Surface observations continued for another 2 h on all animals and signs of DCS were recorded to the nearest minute. RESULTS: Seizure activity at depth was noted in 0/26 controls, 1/16 in the saline group, and 7/16 in the PFC group. DCS in < 2 h occurred in 25/26 air controls, 2/15 in the enriched mix/saline group, and 4/9 not suffering seizure in the enriched mix/PFC group. Death in < 2 h occurred in 23/26 controls, 1/15 in the saline group, and 1/9 in the PFC group. DISCUSSION/CONCLUSION: This study demonstrates the benefits of breathing increased O2 at depth prior to rapid decompression and the deleterious effects of PFC administration at depth in a swine saturation model with rapid decompression. Future studies should examine a minimal O2 pre-breathe period to offer protection against DCS as well as the role of PFC use after surfacing.

Isoproterenol accelerates decompression sickness and death after saturation dives in swine.

BACKGROUND: Disabled submarine (DISSUB) survivors are expected to achieve inert gas tissue saturation that would likely cause severe decompression sickness (DCS). Rescue procedures in a DISSUB scenario cannot accommodate a staged decompression and the availability of recompression treatment chambers is limited. Alternatives to the standard recompression procedures for treating DCS are needed. Experimentally, isoproterenol has successfully addressed many underlying physiological concerns expected to result in cardiopulmonary DCS in this group. HYPOTHESIS: We hypothesized that isoproterenol would reduce the incidence of cardiopulmonary DCS in a saturation dropout model. METHODS: Yorkshire swine (21.8 +/- 1.68 kg) were fitted with an external jugular catheter and compressed to 4.33 ATA in a dry chamber for 22 h. They were infused with isoproterenol (0.002 mg x kg(-1)) while still at depth and returned to the surface without decompression stops. They received additional infusions every 10 min throughout a 2-h observation period. Signs of DCS were recorded to the nearest minute. RESULTS: Isoproterenol administration resulted in a significant increase in the incidence of severe cardiopulmonary DCS (13/34 control vs. 12/18 isoproterenol) and death from DCS (10/34 control vs. 11/18 isoproterenol). There was no difference in the incidence of severe neurological DCS. CONCLUSIONS: Administering isoproterenol as an intervention/treatment for DCS significantly increases the risk of cardiopulmonary DCS and death following saturation dropout in 20-kg swine. As an adjunctive therapy or alternative to staged decompression, isoproterenol in the dose regimen delivered here is not expected to improve outcome in a DISSUB mass casualty scenario.

Definitive 125I prostate brachytherapy implant for low-risk prostate cancer in a patient with an ileal pouch-anal anastomosis: a case report.

PURPOSE: To report on the safe and effective use of a prostate brachytherapy implant for clinically low-risk prostate cancer in a patient with previous ileal pouch-anal anastomosis. METHODS AND MATERIALS: A patient with a previous history of total proctocolectomy with ileal pouch-anal anastomosis was diagnosed with low-risk prostate cancer. He underwent prostate brachytherapy implant and his urinary, bowel, and sexual function were monitored preoperatively and regularly after his implant. RESULTS: Approximately 1-year postimplant, the patient's serum prostate-specific antigen continued to decrease and urinary obstructive symptoms measured via a standardized patient-reported instrument increased transiently but returned to baseline. His sexual function remains slightly diminished. His self-reported bowel function has been essentially unchanged, and he specifically denies increased stool frequency, urgency, incontinence, tenesmus, or hematochezia. CONCLUSIONS: Prostate brachytherapy appears to be both safe and effective for treating low-risk prostate cancer in patients with a pre-existing ileal pouch-anal anastomosis. Although there is a potential for significant late injury to the neorectum, a previous small series indicated that this had not been seen. Models currently used to predict normal tissue complication probabilities do not seem well applied to this case. The developments of algorithms that more correctly model this condition are encouraged.

Metachronous anal canal and prostate cancers with simultaneous definitive therapy: a case report and review of the literature.

Anal canal cancer is rare, accounting for only 1.3% of all gastrointestinal tract malignancies. Prostate cancer incidence is much higher and accounts for 27.6% of all malignancies in men. Treatment guidelines for anal cancer involve radiotherapy to the primary site and draining lymphatics while treatment for prostate cancer can also include pelvic radiotherapy. The literature is silent on the optimum course of action when these two malignancies are found synchronously or metachronously. Herein, we report a case of a patient diagnosed with intermediate risk prostate cancer who, prior to definitive therapy for this first malignancy, was also diagnosed with anal canal cancer. We conclude that a simultaneous approach with radiation therapy and chemotherapy with subsequent boost to the prostate is recommended. Screening for synchronous prostate cancer in male anal canal cancer patients is probably indicated and may preclude suboptimal treatment for a second occult primary.

Aggressive Palliation in Extensive Stage Small Cell Lung Cancer, Practice Guidelines versus Clinical Practice: A Case Report and Review of the Literature.

Small cell lung cancer (SCLC) constitutes approximately 16% of all primary lung cancers, with more than 35,000 new cases per year. Two-thirds of patients present with extensive stage disease (ES-SCLC) due to a tendency to metastasize early. Outcomes remain poor, with a median survival of approximately 10 months and a two-year overall survival of <10%. Current recommendations call for combination chemotherapy alone in patients without localized symptoms. Thoracic radiation therapy following a good clinical response is controversial. We report on a patient with ES-SCLC that had an excellent response to chemotherapy and underwent whole brain radiotherapy for a known brain metastasis and consolidative radiotherapy to the thorax. His latest follow-up demonstrates only a stable residual pulmonary nodule and no evidence of active metastatic disease. ES-SCLC is a relatively common presentation with a variable burden of metastatic disease. In the absence of randomized trials demonstrating the efficacy of thoracic radiation therapy, the community radiation oncologist is placed in a difficult position when addressing these patients, particularly those with otherwise good performance status and a good response to initial systemic chemotherapy. More research in this area is sorely needed to help guide treatment recommendations.

Radiotherapy in the treatment of patients with unresectable extrahepatic cholangiocarcinoma.

PURPOSE: Extrahepatic cholangiocarcinoma is an uncommon but lethal malignancy. We analyzed the role of definitive chemoradiotherapy for patients with nonmetastatic, locally advanced extrahepatic cholangiocarcinoma treated at a single institution. METHODS AND MATERIALS: This retrospective analysis included 37 patients who underwent external beam radiation therapy (EBRT) with concurrent chemotherapy and/or brachytherapy (BT) for locally advanced extrahepatic cholangiocarcinoma. Local control (LC) and overall survival (OS) were assessed, and univariate regression analysis was used to evaluate the effects of patient- and treatment-related factors on clinical outcomes. RESULTS: Twenty-three patients received EBRT alone, 8 patients received EBRT plus BT, and 6 patients received BT alone (median follow-up of 14 months). Two patients were alive without evidence of recurrence at the time of analysis. Actuarial OS and LC rates at 1 year were 59% and 90%, respectively, and 22% and 71%, respectively, at 2 years. Two patients lived beyond 5 years without evidence of recurrence. On univariate analysis, EBRT with or without BT improved LC compared to BT alone (97% vs. 56% at 1 year; 75% vs. 56% at 2 years; p = 0.096). Patients who received EBRT alone vs. BT alone also had improved LC (96% vs. 56% at 1 year; 80% vs. 56% at 2 years; p = 0.113). Age, gender, tumor location (proximal vs. distal), histologic differentiation, EBRT dose (≤ or >50 Gy), EBRT planning method (two-dimensional vs. three-dimensional), and chemotherapy were not associated with patient outcomes. CONCLUSIONS: Patients with locally advanced extrahepatic cholangiocarcinoma have poor survival. Long-term survival is rare. The majority of patients treated with EBRT had local control at the time of death, suggesting that symptoms due to the local tumor effect might be effectively controlled with radiation therapy, and EBRT is an important element of treatment. Novel treatment approaches are indicated in the therapy for this disease.

Biologically effective dose (BED) correlation with biochemical control after low-dose rate prostate brachytherapy for clinically low-risk prostate cancer.

PURPOSE: To assess the correlation of postimplant dosimetric quantifiers with biochemical control of prostate cancer after low-dose rate brachytherapy. METHODS AND MATERIALS: The biologically effective dose (BED), dose in Gray (Gy) to 90% of prostate (D(90)), and percent volume of the prostate receiving 100% of the prescription dose (V(100)) were calculated from the postimplant dose-volume histogram for 140 patients undergoing low-dose rate prostate brachytherapy from 1997 to 2003 at Durham Regional Hospital and the Durham VA Medical Center (Durham, NC). RESULTS: The median follow-up was 50 months. There was a 7% biochemical failure rate (10 of 140), and 91% of patients (127 of 140) were alive at last clinical follow-up. The median BED was 148 Gy (range, 46-218 Gy). The median D(90) was 139 Gy (range, 45-203 Gy). The median V(100) was 85% (range, 44-100%). The overall 5-year biochemical relapse-free survival (bRFS) rate was 90.1%. On univariate Cox proportional hazards modeling, no pretreatment characteristic (Gleason score sum, age, baseline prostate-specific antigen, or clinical stage) was predictive of bRFS. The BED, D(90), and V(100) were all highly correlated (Pearson coefficients >92%), and all were strongly correlated with bRFS. Using the Youden method, we identified the following cut points for predicting freedom from biochemical failure: D(90) >or= 110 Gy, V(100) >or= 74%, and BED >or= 115 Gy. None of the covariates significantly predicted overall survival. CONCLUSIONS: We observed significant correlation between BED, D(90), and V(100) with bRFS. The BED is at least as predictive of bRFS as D(90) or V(100). Dosimetric quantifiers that account for heterogeneity in tumor location and dose distribution, tumor repopulation, and survival probability of tumor clonogens should be investigated.