Thermal imaging of dust hiding the black hole in NGC 1068.

In the widely accepted 'unified model'1 solution of the classification puzzle of active galactic nuclei, the orientation of a dusty accretion torus around the central black hole dominates their appearance. In 'type-1' systems, the bright nucleus is visible at the centre of a face-on torus. In 'type-2' systems the thick, nearly edge-on torus hides the central engine. Later studies suggested evolutionary effects2 and added dusty clumps and polar winds3 but left the basic picture intact. However, recent high-resolution images4 of the archetypal type-2 galaxy NGC 10685,6, suggested a more radical revision. The images displayed a ring-like emission feature that was proposed to be hot dust surrounding the black hole at the radius where the radiation from the central engine evaporates the dust. That ring is too thin and too far tilted from edge-on to hide the central engine, and ad hoc foreground extinction is needed to explain the type-2 classification. These images quickly generated reinterpretations of the dichotomy between types 1 and 27,8. Here we present new multi-band mid-infrared images of NGC 1068 that detail the dust temperature distribution and reaffirm the original model. Combined with radio data (J.F.G. and C.M.V.I., manuscript in preparation), our maps locate the central engine that is below the previously reported ring and obscured by a thick, nearly edge-on disk, as predicted by the unified model. We also identify emission from polar flows and absorbing dust that is mineralogically distinct from that towards the Milky Way centre.

Heimdallr, Baldr, and Solarstein: designing the next generation of VLTI instruments in the Asgard suite.

High angular resolution imaging is an increasingly important capability in contemporary astrophysics. Of particular relevance to emerging fields such as the characterization of exoplanetary systems, imaging at the required spatial scales and contrast levels results in forbidding challenges in the correction of atmospheric phase errors, which in turn drives demanding requirements for precise wavefront sensing. Asgard is the next-generation instrument suite at the European Southern Observatory's Very Large Telescope Interferometer (VLTI), targeting advances in sensitivity, spectral resolution, and nulling interferometry. In this paper, we describe the requirements and designs of three core modules: Heimdallr, a beam combiner for fringe tracking, low order wavefront correction, and visibility science; Baldr, a Zernike wavefront sensor to correct high order atmospheric aberrations; and Solarstein, an alignment and calibration unit. In addition, we draw generalizable insights for designing such system and discuss integration plans.

A proof-of-concept study of iCope: A nurse-led psychoeducational telephone intervention for women attending a rapid diagnostic centre for breast abnormality.

The period between the initial discovery of a suspicious breast lesion and a confirmed diagnosis is a time of significant psychological distress, heightened anxiety, and uncertainty for many women. This proof of concept (PoC) study explored the clinical outcomes and acceptability of iCope, a nurse-led psycho-educational telephone intervention aimed to assist with uncertainty, anxiety and coping in women going through a Rapid Diagnostic Centre (RDC) offering quick diagnosis of breast cancer (same day to three-day post-investigation). Guided by the Uncertainty Theory, and using a one-arm pretest-posttest design, two brief 15-minute telephone sessions were delivered by a nurse prior to the women's day of testing at the RDC and three days after the receipt of their results. Six women completed measures of anxiety, uncertainty, and coping before the clinic visit, three days and three weeks after receiving their test results. Results show that the implementation of the telephone intervention was challenging, yet may offer potential for positive impact. That is, trends of decreased uncertainty and anxiety in participants over time were noted. Considering the difficulty observed in the recruitment and delivering the two interventions in the timeline planned, feasibility testing is recommended before the conduct of a large-scale study.

Optimizing nurses' enacted scope of practice to its full potential as an integrated strategy for the continuous improvement of clinical performance: A multicentre descriptive analysis.

AIM: This study aims at better understanding the relationships between nurses' enacted scope of practice, work environment and work satisfaction, missed care, and organizational indicators of performance. BACKGROUND: The enacted scope of practice model describes the determinants and consequences of the actual enactment of the nursing scope of practice. METHOD: A correlational design was used to investigate nurses' enacted scope of practice in five Canadian healthcare centres. RESULTS: Suboptimal enacted scope of practice were found in the current sample. Significant positive correlations were found between the total enacted scope of practice score, use of qualification, control over tasks, decisional latitude and psychological demand as well as role ambiguity. Moreover, a higher enacted scope of practice was correlated with lower organizational indicators of short-term absenteeism. CONCLUSION: Results suggest an insufficient deployment of nurses' enacted scope of practice, likely caused by some job characteristics, leading to lower work satisfaction and negative patients and organizational outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Optimizing nurses' enacted scope of practice would be a significant integrated strategy for improving organizational performance, patient care and nurses' satisfaction and well-being. Nurses and frontline managers must be involved in the decision-making process necessary to improve nurses' enacted scope of practice.

Chronic Illness Management in Culturally and Linguistically Diverse Patients: Exploring the Needs, Access, and Understanding of Information.

In Canada, people from culturally and linguistically diverse (CALD) backgrounds are at a greater risk of developing a chronic illness, and are more likely to experience adverse health effects and challenges in accessing high-quality care compared with Canadian-born individuals. This, in part, has been attributed to having inadequate access to information and resources needed to manage their illness(es). A qualitative descriptive design and inductive content analysis were used to explore the information needs of 24 CALD patients with chronic illnesses. Participants identified medical, lifestyle, and psychosocial information needs. How much information was needed depended on such antecedents as illness trajectory, severity, and perception. Most information needs remained unmet. A number of communication strategies were identified to bridge language barriers that go beyond translation and are based on effective health education strategies. Findings can help health care professionals better identify CALD patients' information needs and provide strategies that go beyond translation.

The strategic leadership of nursing directorates in the context of healthcare system reform.

In Quebec, the strategic leadership of nursing directorates remains poorly documented despite its importance for the performance of their organizations. Using three focus groups and 31 individual semistructured interviews, a qualitative descriptive study was conducted, including 35 participants from 18 of the Quebec 34 health institutions created in 2015 by the last reform. Seven themes emerged: (1) taking ownership of the strategic positioning, (2) developing and communicating a vision, (3) making strategic, systematic, and measured choices, (4) reframing roles, (5) getting involved in the strategic decision-making processes, (6) developing the political capacity, and (7) building alliances. Four professional and organizational components influenced the nursing directorates' leadership capacity: clinical credibility, a sufficient number of people educated at the graduate level, organizational culture, and size of the institution. It is expected that these results regarding nursing directorates' exercise of strategic leadership will lead to better governance and quality of nursing care.

Web-Based Tailored Nursing Intervention to Support Medication Self-management: A Qualitative Study of the Experience of Kidney Transplant Recipients.

Optimal adherence to immunosuppressive medication is essential to kidney graft success. A Web-based tailored virtual nursing intervention was developed to promote medication adherence and support self-management among kidney transplant recipients. A qualitative study was undertaken in a hospital setting in Montreal (Canada) to document how users experience the intervention and to explore medication intake self-management behaviors. To participate, transplant recipients had to be at least 18 years old and had to have completed at least one computer session of the intervention. Semistructured interviews were conducted with 10 participants (two women, eight men) with a mean age of 47.8 years. They reported receiving their latest renal transplant on average 10.6 years prior. Content analysis of the interview transcripts yielded five major themes: (1) kidney transplant is a gift from life; (2) routinization of medication intake; (3) intervention is a new and positive experience; (4) using the intervention offers many benefits; and (5) individual relevance of the intervention. Patient experience shows the intervention is acceptable and can help better manage medication intake. Results also underscore the importance of offering the intervention early in the care trajectory of transplant recipients. Web-based tailored virtual nursing interventions could constitute an easily available adjunct to existing specialized services.

A hot compact dust disk around a massive young stellar object.

Circumstellar disks are an essential ingredient of the formation of low-mass stars. It is unclear, however, whether the accretion-disk paradigm can also account for the formation of stars more massive than about 10 solar masses, in which strong radiation pressure might halt mass infall. Massive stars may form by stellar merging, although more recent theoretical investigations suggest that the radiative-pressure limit may be overcome by considering more complex, non-spherical infall geometries. Clear observational evidence, such as the detection of compact dusty disks around massive young stellar objects, is needed to identify unambiguously the formation mode of the most massive stars. Here we report near-infrared interferometric observations that spatially resolve the astronomical-unit-scale distribution of hot material around a high-mass ( approximately 20 solar masses) young stellar object. The image shows an elongated structure with a size of approximately 13 x 19 astronomical units, consistent with a disk seen at an inclination angle of approximately 45 degrees . Using geometric and detailed physical models, we found a radial temperature gradient in the disk, with a dust-free region less than 9.5 astronomical units from the star, qualitatively and quantitatively similar to the disks observed in low-mass star formation. Perpendicular to the disk plane we observed a molecular outflow and two bow shocks, indicating that a bipolar outflow emanates from the inner regions of the system.

Interprofessional patient-centred practice in oncology teams: utopia or reality?

Studies on interprofessional practice usually report professionals' viewpoints and document organizational, procedural and relational factors influencing that practice. Considering the importance of interprofessional patient-centred (IPPC) practice, it seems necessary to describe it in detail in an actual context of care, from the perspective of patients, their families and health-care professionals. The goal of this study was to describe IPPC practice throughout the continuum of cancer care. A qualitative multiple case study was completed with two interprofessional teams from a Canadian teaching hospital. Interviews were conducted with patients, their families and professionals, and observation was carried out. Three themes were illustrated by current team practice: welcoming the person as a unique individual, but still requiring the patient to comply; the paradoxical coexistence of patient-centred discourse and professional-centred practice; and triggering team collaboration with the culmination of the patient's situation. Several influential factors were described, including the way the team works; the physical environment; professionals' and patients'/family members' stance on the collaboration; professionals' stance on patients and their families; and patients' stance on professionals. Finally, themes describing the desired IPPC practice reflect the wish of most participants to be more involved. They were: providing support in line with the patient's experience and involvement; respecting patients by not imposing professionals' values and goals; and consistency and regularity in the collaboration of all members.

The care continuum with interprofessional oncology teams: Perspectives of patients and family.

To accompany the individual diagnosed with cancer along the care continuum, teams of professionals have been created based on integrating an interprofessional patient-centred (IPPC) practice. The goal of this article is to present some of the results of a case study documenting IPPC practice carried on by teams within the oncology care continuum. Observations and interviews with patients and their family were conducted. The results suggest that IPPC practice is variable within teams, but optimal at the beginning of treatments or cancer recurrence. However, patients can experience breakdowns in the continuity of care and more difficult transitions between oncology continuum periods (diagnosis, treatment, follow-up).

Contribution of the pivot nurse in oncology to the experience of receiving a diagnosis of cancer by the patient and their loved ones.

The announcement of a cancer diagnosis represents a difficult situation for the patient, their loved ones and professionals (Reich, Vennin & Belkacémie, 2008). Until now, few studies have described nurses' contribution to this critical moment along the care trajectory (Tobin, 2012) and even fewer, the contribution of the pivot nurse in oncology (OPN) or infirmière pivot en oncologie (PNO) as this specialist is called in Quebec. This study aims to document the OPN's contribution to the cancer experience of the patient and their loved ones, from the time the diagnosis is communicated to the period immediately following (four to six weeks). Fourteen PNOs from a Montreal university health centre took part in two individual interviews. Results show that PNOs offer personalized support which draws on their expertise to better understand the experience lived by patients and their loved ones, and adapt their interventions according to their needs and the timing of these interventions. These results support issuing three recommendations for nursing practice in the areas of PNOs; development of expertise, interprofessional collaboration and environment.

La transformation du réseau québécois de la santé : une opportunité de repositionnement stratégique des soins infirmiers.

Dans le cadre de la mise en place d'une nouvelle gouvernance du réseau de la santé et des services sociaux du Québec, la Direction nationale de soins et services infirmiers (DNSSI) du ministère de la Santé et des Services sociaux (MSSS) a réalisé une démarche de repositionnement stratégique. L'objectif visait à favoriser l'exercice d'un leadership infirmier efficace et dont les actions sont porteuses de changements, pour ultimement influencer la définition des politiques et des orientations nationales en santé. Après une brève mise en contexte, cet article résume les grandes étapes de la démarche de repositionnement réalisée en partenariat avec les directrices de soins infirmiers (DSI) du réseau de la santé et des services sociaux (RSSS) et les résultats qui en découlent. L'article présente également le processus menant à la détermination des priorités de la DNSSI, la nature des actions posées par cette dernière et les considérations tenues en compte dans le choix de ses actions. Il conclut sur les retombées de la démarche de repositionnement.

[The contribution of nursing science to interprofessional knowledge development]. / Contribution des sciences infirmières au développement des savoirs interprofessionnels.

Health professionals have to work together to ensure quality patient care.There are many studies exploring interprofessional education and practice. However, interprofessional knowledge is related to teamwork and organizational context. Some frameworks include "patient-centered" concepts to highlight the contribution of the patient but descriptions of the patient's contribution to the interprofessional practice are limited. Nursing professionals develop extensive expertise as a patient-centered professional practice and their experience can inspire new collaborative approaches.This article aims to summarize the state of knowledge regarding interprofessional practice and patient-centered nursing expertise.We also highlight the contribution of nursing in developing this approach and the ways in which nursing contributes to the development of interprofessional knowledge that is consistent with its values.

[The development of clinical reasoning skills and leadership: personal factors and organizational factors]. / Le développement continu des compétences de raisonnement clinique et de leadership: facteurs personnels et facteurs organisationnels.

Continuing education of newly graduated nurses (NGN) depends on several factors related to the characteristics of skills to be developed, the target population and the organizational context. Few studies describe both how nurses develop their skills and how institutions promote this development. The objectives of this manuscript are to (1) describe the behaviors that the NGN use to develop their reasoning skills and leadership and (2) document the organizational elements that facilitate this development. Method. Individual interviews were conducted with nurses (n = 34) using a grid of semistructured interviews and two group interviews were conducted with nurses (n = 7) and managers (n = 19) in two teaching hospitals in eastern Canada. The results show that nurses develop mainly by reflecting on their professional practice in their workplace. However, the lack of time for reflection in the workspace is a considerable obstacle while managerial leadership is an important asset.

[Project evaluation of nursing interventions: an algorithm to support the practice of clinicians]. / Evaluation de projets d'interventions infirmières: un algorithme pour soutenir la pratique des cliniciennes.

It is recognized that nurses regularly have to adapt their clinical practice compared to new scientific breakthroughs. However, changes in practice are possible by the implementation of clinical projects but can sometimes be long and difficult to achieve in health care settings, given the context of care or the profile of the clientele, the care organization, work organization, etc. An algorithmic approach (i.e., sequence of actions) to support nurses in the evaluation of new nursing intervention projects, including other members of the interdisciplinary team, researchers, and patients and their relatives, has been developed. This algorithm considers the clinical environment in which the project will operationalize nursing interventions and involves five steps: 1) identification and description of a care problem to solve or a care practice to improve; 2) the development or adaptation of appropriate nursing intervention, and 3) the choice of evaluation design for this nursing intervention, and 4) testing of the intervention and 5) implementation and reflection on the process.

[Educational innovation among nurses in the context of early work experience]. / L'innovation pédagogique chez les infirmières dans un contexte de début d'expérience professionnelle.

During their integration into the health system, new nursing graduates encounter many challenges, in particular with health situations that are becoming ever more complex. They frequently see clinical situations they have not previously been exposed to--an inevitability given the variety and complexity of real-world practice. It is therefore essential to adequately support and equip new nurses for the particular context within which they will be working in the Quebec health care system, while enabling them to provide quality care. Educational innovation is one way to meet the needs of this new generation which will have to learn to navigate in the health system and be rapidly functional. This paper presents a definition and a contextualisation of educational innovation. It will highlight the incentives and barriers to innovation, will describe its impact on training and clinical practice and will differentiate the strategies which lead to the development of innovation. Finally, different levers to ensure sustainability of the innovation will be discussed.

The effect of culturally-adapted health education interventions among culturally and linguistically diverse (CALD) patients with a chronic illness: A meta-analysis and descriptive systematic review.

OBJECTIVE: To review the effectiveness of health education interventions adapted for culturally and linguistically diverse (CALD) populations with a chronic illness. METHODS: A systematic review and meta-analysis were conducted. Eligible studies were identified across six databases. Data were extracted and intervention effect was summarized using standardized mean difference. If there were insufficient data for meta-analysis, a descriptive summary was included. Modifying effects of intervention format, length, intensity, provider, self-management skills taught, and behavioral change techniques (BCTs) utilized were examined. RESULTS: 58 studies were reviewed and data were extracted for 36 outcomes. Most interventions used multiple modes of delivery and were facilitated by bilingual health care professionals (HCPs). On average, interventions included 5.19 self-management skills and 4.82 BCTs. Interventions were effective in reducing BMI, cholesterol, triglycerides, blood glucose, HbA1C, and depression, and in increasing knowledge. Effectiveness was influenced partly by provider, with HCPs favored over lay providers or paraprofessionals in increasing knowledge; however, the opposite was noted for HbA1c. CONCLUSIONS: Health education interventions are effective among CALD populations, particularly at improving objective, distal outcomes (e.g., anthropometric measures). These interventions may be equally effective in improving proximal patient-reported outcomes (PROs); however, diversity in PROs limited analyses. PRACTICE IMPLICATIONS: Core outcome sets (COS) are needed to further investigate and compare health education intervention effectiveness on PROs.

Adaptation and validation of a nursing competencies framework for clinical practice on a continuum of care from childhood to adulthood: A Delphi study.

BACKGROUND: Too few of nursing competencies framework exceed applicability to a given environment, are validated by a research process or used to guide continuing development of nursing competencies. OBJECTIVES: The study objectives were: 1) to adapt and validate a nursing competencies framework from the continuum of care from childhood to adulthood and 2) to explore implementation strategies. DESIGN: A collaborative approach including nurses from different practice perspectives. A modified Delphi method supported the adaptation and the validation of a nursing competencies framework. SETTING: This study was conducted in a pediatric and an adult care university hospitals in Montreal. PARTICIPANTS: Forty-two nurses were recruited from both university hospitals. METHODS: A modified Delphi study was conducted. An online questionnaire, containing dichotomous and open-ended questions, was used to collect data on the nursing competencies framework and the suggested implementation strategies for its use. Consensus percentage was calculated, and thematic analysis was used to analyze nurses' comments and implementation strategies suggested. RESULTS: The nursing competencies framework (NCF), adapted and validated in this study, includes seven competencies and four development stages, from advanced beginner to clinical expert nurses. After three rounds, the nursing competencies framework describes the professional role from the continuum of care from childhood to adulthood, and proposes a self-assessment tool that promotes professional development and continuing education of nurses. Moreover, four strategies for implementing the framework in the clinical setting obtained a consensus of 70% or more. CONCLUSIONS: A nursing competencies framework was validated by a rigorous research process and adapted to diverse contexts of care. The results revealed a common vision of the nursing practice for patients and their families on the life course from childhood to adulthood. This innovative framework carries the potential to be a relevant and unique reference tool. The nursing competencies framework can provide guidance for the development of nurses' competencies in clinical setting. Additionally, it is a relevant reference that should be use for knowing the scope and the standards of the professional practice in nursing education.

A second generation of the competency-based approach to nursing education.

This article describes the renewal of a baccalaureate program in nursing. This new program was developed to respond to new challenges presented to the profession. A completely new approach was adopted, the competency-based approach (CBA), with a constructivist, holistic foundation that we named 'second generation CBA.' The CBA theoretical underpinnings are presented, as well as the structure and the content of the program with a special focus on the teaching and learning strategies. A course on health illustrates the approach. Although no rigorous evaluation has been held, comments from students and teachers were collected during the implementation process. Assessment of students' competency levels remains an important issue.