Clinical education models in rural practice settings: A scoping review.

AIM: The objective of this review is to identify and synthesize the literature on clinical nursing education models in rural settings, with the goal of developing a better understanding of effective clinical education models suitable for rural nursing education. BACKGROUND: Clinical education is an integral part of nursing education, yet very little clinical education occurs in rural and remote areas. This leaves the rural landscape vulnerable to inadequate health care staffing because many graduates will begin their nursing practice in the geographical areas where they studied. The rural nursing workforce is currently insufficient to meet the health care needs of rural populations. This insufficiency is likely to worsen because statistical trends suggest that rural and remote communities might be among the worst affected by the global nursing shortage. Many new graduate nurses are ill prepared for rural nursing practice, primarily due to limited exposure to rural nursing content and rural clinical experiences in their entry-to-practice education. Increasing opportunities for nursing students to learn in rural clinical settings will likely support the recruitment and retention of nurses in rural practice. Despite the key role of rural nursing education in sustaining the rural health workforce, little is known about rural clinical learning in nursing education. DESIGN: A scoping review. METHODS: This scoping review was conducted using the steps outlined by Arksey and O'Malley with updated methodological guidance from the Joanna Briggs Institute. RESULTS: Of 1880 potential data sources, 82 were included in data analysis. Although no distinct model of rural clinical nursing education could be identified, several features of clinical nursing education were described in the context of rural clinical learning. Preceptorship was the most used mentorship/clinical supervision model (n=41). The most common placement design was a block model design (n=41) lasting between one and 16 weeks, with most learners engaging in episodic care with individual clients (n=42). Interestingly, 24 sources reported learners engaging in rural clinical education across multiple contexts (e.g., acute care, home care, and primary care). CONCLUSION: These findings suggest there exists great variability in rural clinical learning opportunities for nursing students. Academic practice partnerships could continue to be leveraged to provide learners with rural clinical education that meets the needs of both the educational institution as well as the rural communities in which learning takes place. An area of further research would be to focus on formal evaluation of the effectiveness of clinical education models in the rural context.

GRASSY TILLERS1 (GT1) and SIX-ROWED SPIKE1 (VRS1) homologs share conserved roles in growth repression.

Crop engineering and de novo domestication using gene editing are new frontiers in agriculture. However, outside of well-studied crops and model systems, prioritizing engineering targets remains challenging. Evolution can guide us, revealing genes with deeply conserved roles that have repeatedly been selected in the evolution of plant form. Homologs of the transcription factor genes GRASSY TILLERS1 (GT1) and SIX-ROWED SPIKE1 (VRS1) have repeatedly been targets of selection in domestication and evolution, where they repress growth in many developmental contexts. This suggests a conserved role for these genes in regulating growth repression. To test this, we determined the roles of GT1 and VRS1 homologs in maize (Zea mays) and the distantly related grass brachypodium (Brachypodium distachyon) using gene editing and mutant analysis. In maize, gt1; vrs1-like1 (vrl1) mutants have derepressed growth of floral organs. In addition, gt1; vrl1 mutants bore more ears and more branches, indicating broad roles in growth repression. In brachypodium, Bdgt1; Bdvrl1 mutants have more branches, spikelets, and flowers than wild-type plants, indicating conserved roles for GT1 and VRS1 homologs in growth suppression over ca. 59 My of grass evolution. Importantly, many of these traits influence crop productivity. Notably, maize GT1 can suppress growth in arabidopsis (Arabidopsis thaliana) floral organs, despite ca. 160 My of evolution separating the grasses and arabidopsis. Thus, GT1 and VRS1 maintain their potency as growth regulators across vast timescales and in distinct developmental contexts. This work highlights the power of evolution to inform gene editing in crop improvement.

Personalized RNA neoantigen vaccines stimulate T cells in pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) is lethal in 88% of patients1, yet harbours mutation-derived T cell neoantigens that are suitable for vaccines 2,3. Here in a phase I trial of adjuvant autogene cevumeran, an individualized neoantigen vaccine based on uridine mRNA-lipoplex nanoparticles, we synthesized mRNA neoantigen vaccines in real time from surgically resected PDAC tumours. After surgery, we sequentially administered atezolizumab (an anti-PD-L1 immunotherapy), autogene cevumeran (a maximum of 20 neoantigens per patient) and a modified version of a four-drug chemotherapy regimen (mFOLFIRINOX, comprising folinic acid, fluorouracil, irinotecan and oxaliplatin). The end points included vaccine-induced neoantigen-specific T cells by high-threshold assays, 18-month recurrence-free survival and oncologic feasibility. We treated 16 patients with atezolizumab and autogene cevumeran, then 15 patients with mFOLFIRINOX. Autogene cevumeran was administered within 3 days of benchmarked times, was tolerable and induced de novo high-magnitude neoantigen-specific T cells in 8 out of 16 patients, with half targeting more than one vaccine neoantigen. Using a new mathematical strategy to track T cell clones (CloneTrack) and functional assays, we found that vaccine-expanded T cells comprised up to 10% of all blood T cells, re-expanded with a vaccine booster and included long-lived polyfunctional neoantigen-specific effector CD8+ T cells. At 18-month median follow-up, patients with vaccine-expanded T cells (responders) had a longer median recurrence-free survival (not reached) compared with patients without vaccine-expanded T cells (non-responders; 13.4 months, P = 0.003). Differences in the immune fitness of the patients did not confound this correlation, as responders and non-responders mounted equivalent immunity to a concurrent unrelated mRNA vaccine against SARS-CoV-2. Thus, adjuvant atezolizumab, autogene cevumeran and mFOLFIRINOX induces substantial T cell activity that may correlate with delayed PDAC recurrence.

Boundary domain genes were recruited to suppress bract growth and promote branching in maize.

Grass inflorescence development is diverse and complex and involves sophisticated but poorly understood interactions of genes regulating branch determinacy and leaf growth. Here, we use a combination of transcript profiling and genetic and phylogenetic analyses to investigate tasselsheath1 (tsh1) and tsh4, two maize genes that simultaneously suppress inflorescence leaf growth and promote branching. We identify a regulatory network of inflorescence leaf suppression that involves the phase change gene tsh4 upstream of tsh1 and the ligule identity gene liguleless2 (lg2). We also find that a series of duplications in the tsh1 gene lineage facilitated its shift from boundary domain in nongrasses to suppressed inflorescence leaves of grasses. Collectively, these results suggest that the boundary domain genes tsh1 and lg2 were recruited to inflorescence leaves where they suppress growth and regulate a nonautonomous signaling center that promotes inflorescence branching, an important component of yield in cereal grasses.

Neoantigen quality predicts immunoediting in survivors of pancreatic cancer.

Cancer immunoediting1 is a hallmark of cancer2 that predicts that lymphocytes kill more immunogenic cancer cells to cause less immunogenic clones to dominate a population. Although proven in mice1,3, whether immunoediting occurs naturally in human cancers remains unclear. Here, to address this, we investigate how 70 human pancreatic cancers evolved over 10 years. We find that, despite having more time to accumulate mutations, rare long-term survivors of pancreatic cancer who have stronger T cell activity in primary tumours develop genetically less heterogeneous recurrent tumours with fewer immunogenic mutations (neoantigens). To quantify whether immunoediting underlies these observations, we infer that a neoantigen is immunogenic (high-quality) by two features-'non-selfness'  based on neoantigen similarity to known antigens4,5, and 'selfness'  based on the antigenic distance required for a neoantigen to differentially bind to the MHC or activate a T cell compared with its wild-type peptide. Using these features, we estimate cancer clone fitness as the aggregate cost of T cells recognizing high-quality neoantigens offset by gains from oncogenic mutations. With this model, we predict the clonal evolution of tumours to reveal that long-term survivors of pancreatic cancer develop recurrent tumours with fewer high-quality neoantigens. Thus, we submit evidence that that the human immune system naturally edits neoantigens. Furthermore, we present a model to predict how immune pressure induces cancer cell populations to evolve over time. More broadly, our results argue that the immune system fundamentally surveils host genetic changes to suppress cancer.

Two MYB Proteins in a Self-Organizing Activator-Inhibitor System Produce Spotted Pigmentation Patterns.

Many organisms exhibit visually striking spotted or striped pigmentation patterns. Developmental models predict that such spatial patterns can form when a local autocatalytic feedback loop and a long-range inhibitory feedback loop interact. At its simplest, this self-organizing network only requires one self-activating activator that also activates a repressor, which inhibits the activator and diffuses to neighboring cells. However, the molecular activators and inhibitors fully fitting this versatile model remain elusive in pigmentation systems. Here, we characterize an R2R3-MYB activator and an R3-MYB repressor in monkeyflowers (Mimulus). Through experimental perturbation and mathematical modeling, we demonstrate that the properties of these two proteins correspond to an activator-inhibitor pair in a two-component, reaction-diffusion system, explaining the formation of dispersed anthocyanin spots in monkeyflower petals. Notably, disrupting this pattern impacts pollinator visitation. Thus, subtle changes in simple activator-inhibitor systems are likely essential contributors to the evolution of the remarkable diversity of pigmentation patterns in flowers.

Lagging Adaptation to Climate Supersedes Local Adaptation to Herbivory in an Annual Monkeyflower.

While native populations are often adapted to historical biotic and abiotic conditions at their home site, populations from other locations in the range may be better adapted to current conditions due to changing climates or extreme conditions in a single year. We examine whether local populations of a widespread species maintain a relative advantage over distant populations that have evolved at sites better matching the current climate. Specifically, we grew lines derived from low- and high-elevation annual populations in California and Oregon of the common monkeyflower (Erythranthe guttata) and conducted phenotypic selection analyses in low- and high-elevation common gardens in Oregon to examine relative fitness and the traits mediating relative fitness. Californian low-elevation populations have the highest relative fitness at the low-elevation site, and Californian high-elevation populations have the highest relative fitness at the high-elevation site. Relative fitness differences are mediated by selection for properly timed transitions to flowering, with selection favoring more rapid growth rates at the low-elevation site and greater vegetative biomass prior to flowering at the high-elevation site. Fitness advantages for Californian plants occur despite incurring higher herbivory at both sites than the native Oregonian plants. Our findings suggest that a lag in adaptation causes maladaptation in extreme years that may be more prevalent in future climates, but local populations still have high growth rates and thus are not yet threatened.

The role of unregulated care providers in home care: A scoping review.

AIM AND BACKGROUND: Health care needs of individuals living in the community are increasing. To meet the rising need, unregulated care providers are providing more complex patient care. The aim of this review is to articulate the unregulated care provider role by identifying patient care activities offered by unregulated care providers in home care. METHODS: A scoping review was conducted. One thousand and eleven published manuscripts were identified in CINAHL, Ageline and MEDLINE. Eleven additional manuscripts were identified through hand searching. Manuscripts were screened for relevancy and data were abstracted to address the research question. RESULTS: Twenty-eight studies originating from Canada, Sweden, Belgium, UK, USA and New Zealand were included. Three categories of patient care activities provided by unregulated care providers were found: (1) personal care and core skills; (2) delegated tasks and added skills; and (3) specialty roles. CONCLUSION: Unregulated care providers predominantly provide assistance with personal care and activities of daily living. However, unregulated care providers also provide care outside their training, including care once provided by nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Guidelines clearly articulating responsibilities of nurses transferring care activities to unregulated care providers should be developed. Processes and policies regarding evaluation and supervision of unregulated care providers providing added skills should be developed to ensure appropriate monitoring and support.

Leadership rounds to reduce health care-associated infections.

BACKGROUND: Evidence-based guidelines exist to reduce health care-associated infections (HAIs). Leadership rounds are one tool leaders can use to ensure compliance with guidelines, but have not been studied specifically for the reduction of HAIs. This study examines HAI leadership rounds at one facility. METHODS: We explored unit-based HAI leadership rounds led by 2 hospital leaders at a large academic hospital. Leadership rounds were observed on 19 units, recorded, and coded to identify themes. Themes were linked to the Consolidated Framework for Implementation Research and used to guide interviews with frontline staff members. RESULTS: Staff members disclosed unit-specific problems and readily engaged in problem-solving with top hospital leaders. These themes appeared over 350 times within 22 rounds. Findings revealed that leaders used words that demonstrated fallibility and modeled curiosity, 2 factors associated with learning climate and psychologic safety. These 2 themes appeared 115 and 142 times, respectively. The flexible nature of the rounds appeared to be conducive for reflection and evaluation, which was coded 161 times. CONCLUSIONS: Each interaction between leaders and frontline staff can foster psychologic safety, which can lead to open problem-solving to reduce barriers to implementation. Discovering specific communication and structural factors that contribute to psychologic safety may be powerful in reducing HAIs.

The evolving role of the personal support worker in home care in Ontario, Canada.

To meet increasing demand for home care, the role of personal support workers (PSWs) is shifting from providing primarily personal and supportive care to include care activities previously provided by regulated health professionals (RHPs). Much of the research examining this shift focuses on specialty programmes, with few studies investigating the daily care being provided by PSWs, frequency of care activities being provided by PSWs, and characteristics of the population receiving more complex tasks. Between January and April 2015, a review of 517 home-care service user charts was undertaken in Ontario, Canada, to: (1) describe the range of tasks being performed by PSWs in home care, (2) identify tasks transferred by RHPs to PSWs, and (3) examine characteristics of service users receiving transferred care. Findings indicate that normally, PSWs provide personal and supportive care commensurate with their training. However, in approximately one quarter of care plans reviewed, PSWs also completed more complex care activities transferred to them by RHPs. Service users receiving transferred care were older and had higher levels of cognitive and functional impairment. Although there is potential for the expansion of home-care services through increased utilisation of PSWs, healthcare leadership must ensure that the right provider is being utilised at the right time and in the right place to ensure safe and effective quality care. Thus, several actions are recommended: PSW core competencies be clearly articulated, processes used to transfer care activities from RHPs to PSWs be standardised and a team-based approach to the delivery of home-care services be considered. Utilisation of a team-based model can help establish positive relationships among home-care providers, provide increased support for PSWs, allow for easier scheduling of initial training and ensure regular reassessments of PSW competence among PSWs providing added skills.

Home-based care: barriers and facilitators to expanded personal support worker roles in Ontario, Canada.

To accommodate the increasing demand for home care in Ontario, Canada, some care tasks traditionally performed by regulated health professionals are being transferred to personal support workers (PSW). However, this expansion of PSW roles is not uniform across the province. Between December 2014 and April 2015, barriers and facilitators to expansion of PSW roles in home care were explored in a series of 13 focus groups. Home care staff identified seven categories of factors affecting the expansion of PSW roles in home care including: communication and documentation; organization and structures of care; attitudes and perceptions of the expanding PSW role; adequate staffing; education, training and support; PSW role clarity and variation in practices, policies, and procedures. Addressing barriers and promoting facilitators at the funder and employer levels will enable the provision of safe, effective, and equitable care by PSWs.

Implementation in the midst of complexity: Using ethnography to study health care-associated infection prevention and control.

BACKGROUND: Contextual factors associated with health care settings make reducing health care-associated infections (HAIs) a complex task. The aim of this article is to highlight how ethnography can assist in understanding contextual factors that support or hinder the implementation of evidence-based practices for reducing HAIs. METHODS: We conducted a review of ethnographic studies specifically related to HAI prevention and control in the last 5 years (2012-2017). RESULTS: Twelve studies specific to HAIs and ethnographic methods were found. Researchers used various methods with video-reflexive sessions used in 6 of the 12 studies. Ethnography was used to understand variation in data reporting, identify barriers to adherence, explore patient perceptions of isolation practices and highlight the influence of physical design on infection prevention practices. The term ethnography was used to describe varied research methods. Most studies were conducted outside the United States, and authors indicate insights gained using ethnographic methods (whether observations, interviews, or reflexive video recording) as beneficial to unraveling the complexities of HAI prevention. CONCLUSIONS: Ethnography is well-suited for HAI prevention, especially video-reflexive ethnography, for activating patients and clinicians in infection control work. In this era of increasing pressure to reduce HAIs within complex work systems, ethnographic methods can promote understanding of contextual factors and may expedite translation evidence to practice.

Occupational hazards for home care nurses across the rural-to-urban gradient in Ontario, Canada.

The purpose of this paper was to describe occupational hazards for nurses working in home care (HC) and explore how they differ across the rural-to-urban gradient. Responses (n = 823) from a cross-sectional survey conducted in 2012 of HC nurses registered to practise nursing in the Province of Ontario, Canada were used. Using chi-square analysis and posthoc pairwise tests with a Bonferroni correction, 14 occupational hazards were individually tested for differences between four geographical settings (rural, town, suburban or urban areas). Our study reports that in addition to common occupational hazards that all HC nurses experience, the frequency of experiencing some hazards varies based on geographic setting. These specific hazards include exposure to: aggressive pets, environmental tobacco smoke, oxygen equipment, unsafe neighbourhoods and pests. Findings from this study suggest that a relationship exists between where a patient's home is located and the types of occupational hazards that may be experienced by HC staff. This research is useful for HC organisations in developing staff training programmes to recognise and manage occupational hazards that workers are likely to encounter. Home healthcare and policy leaders may use these findings to develop and implement educational and other strategies to reduce risk and manage exposures across the rural-to-urban gradient.

Work-related factors influencing home care nurse intent to remain employed.

BACKGROUND: Health care is shifting out of hospitals into community settings. In Ontario, Canada, home care organizations continue to experience challenges recruiting and retaining nurses. However, factors influencing home care nurse retention that can be modified remain largely unexplored. Several groups of factors have been identified as influencing home care nurse intent to remain employed including job characteristics, work structures, relationships and communication, work environment, responses to work, and conditions of employment. PURPOSE: The aim of this study was to test and refine a model that identifies which factors are related to home care nurse intentions to remain employed for the next 5 years with their current home care employer organization. METHODOLOGY/APPROACH: A cross-sectional survey design was implemented to test and refine a hypothesized model of home care nurse intent to remain employed. Logistic regression was used to determine which factors influence home care nurse intent to remain employed. FINDINGS: Home care nurse intent to remain employed for the next 5 years was associated with increasing age, higher nurse-evaluated quality of care, having greater variety of patients, experiencing greater meaningfulness of work, having greater income stability, having greater continuity of client care, experiencing more positive relationships with supervisors, experiencing higher work-life balance, and being more satisfied with salary and benefits. PRACTICE IMPLICATIONS: Home care organizations can promote home care nurse intent to remain employed by (a) ensuring nurses have adequate training and resources to provide quality client care, (b) improving employment conditions to increase income stability and satisfaction with pay and benefits,

Understanding Inpatient Perceptions of Indwelling Urinary Catheters Using the Health Belief Model.

Patient interviews using the Health Belief Model framework identified thematic patient perceptions of indwelling urinary catheters and catheter-associated urinary tract infections. Generally, patients perceived catheters as convenient and were unaware of catheter alternatives and risks for infection. Better patient education is needed to reduce urinary catheter use and infections. Infect Control Hosp Epidemiol 2016;37:1098-1100.

Generation-specific incentives and disincentives for nurse faculty to remain employed.

AIMS: The aims of this paper are to: (1) describe work characteristics that nurse faculty report encourage them to remain in or leave their academic positions; and (2) determine if there are generational differences in work characteristics selected. BACKGROUND: Nurse faculty play key roles in preparing new nurses and graduate nurses. However, educational institutions are challenged to maintain full employment in faculty positions. DESIGN: A cross-sectional, descriptive survey design was employed. METHODS: Ontario nurse faculty were asked to select, from a list, work characteristics that entice them to remain in or leave their faculty positions. Respondent data (n = 650) were collected using mailed surveys over four months in 2011. RESULTS: While preferred work characteristics differed across generations, the most frequently selected incentives enticing nurse faculty to stay were having: a supportive director/dean, reasonable workloads, supportive colleagues, adequate resources, manageable class sizes and work/life balance. The most frequently selected disincentives included: unmanageable workloads, unsupportive organizations, poor work environments, exposure to bullying, belittling and other types of incivility in the workplace and having an unsupportive director/dean. CONCLUSION: This research yields new and important knowledge about work characteristics that nurse faculty report shape their decisions to remain in or leave their current employment. Certain work characteristics were rated as important among all generations. Where similarities exist, broad strategies addressing work characteristics may effectively promote nurse faculty retention. However, where generational differences exist, retention-promoting strategies should target generation-specific preferences.

Work, work environments and other factors influencing nurse faculty intention to remain employed: a cross-sectional study.

BACKGROUND: Given the role nurse faculty have in educating nurses, little is known about what influences their intention to remain employed (ITR) in academic settings. OBJECTIVES: Findings from a nurse faculty survey administered to test a conceptual model of factors hypothesized as influencing nurse faculty ITR are reported. DESIGN: A cross-sectional survey design was employed. SETTING: We included colleges and universities in Ontario, Canada. PARTICIPANTS: The population of Ontario nurse faculty who reported being employed as nurse faculty with the College of Nurses of Ontario (Canada) was included. Of the 1328 nurse faculty who were surveyed, 650 participated. METHODS: Participants completed a questionnaire with measures of work, work environment, job satisfaction, burnout and ITR. Regression analyses were conducted to test the model. RESULTS: Ten of 26 independent variables explained 25.4% of variance in nurse faculty ITR for five years. These variables included: proximity to retirement, quality of relationships with colleagues, being employed full time, having dependents, satisfaction with work-life balance, quality of education, satisfaction with job status, access to financial support for education from organization, access to required human resources and being unionized. CONCLUSIONS: Although not all influencing factors are modifiable, academic leadership should develop strategies that encourage nurse faculty ITR. Strategies that support collegial relationships among faculty, increase the number of full time positions, promote work-life balance, engage faculty in assessing and strengthening education quality, support faculty choice between full-time and part-time work, and ensure adequate human resources required to teach effectively will lead to heightened nurse faculty ITR.

Factors influencing home care nurse intention to remain employed.

AIM: To identify factors affecting Canadian home care nurse intention to remain employed (ITR). BACKGROUND: In developed nations, healthcare continues to shift into community settings. Although considerable research exists on examining nurse ITR in hospitals, similar research related to nurses employed in home care is limited. In the face of a global nursing shortage, it is important to understand the factors influencing nurse ITR across healthcare sectors. METHODS: A qualitative exploratory descriptive design was used. Focus groups were conducted with home care nurses. Data were analysed using qualitative content analysis. RESULTS: Six categories of influencing factors were identified by home care nurses as affecting ITR: job characteristics; work structures; relationships/communication; work environment; nurse responses to work; and employment conditions. CONCLUSION: Findings suggest the following factors influence home care nurse ITR: having autonomy; flexible scheduling; reasonable and varied workloads; supportive work relationships; and receiving adequate pay and benefits. Home care nurses did not identify job satisfaction as a single concept influencing ITR. IMPLICATIONS FOR NURSING MANAGEMENT: Home care nursing management should support nurse autonomy, allow flexible scheduling, promote reasonable workloads and create opportunities for team building that strengthen supportive relationships among home care nurses and other health team members.