Adapting a Financial Incentives Intervention for Smoking Cessation with Alaska Native Families: Phase 1 Qualitative Research to Inform the Aniqsaaq (To Breathe) Study.

INTRODUCTION: Alaska Native and American Indian (ANAI) peoples in Alaska currently experience a disproportionate burden of morbidity and mortality from tobacco cigarette use. Financial incentives for smoking cessation are evidence-based, but a family-level incentive structure has not been evaluated. We used a community-based participatory research and qualitative approach to culturally adapt a smoking cessation intervention with ANAI families. METHODS: We conducted individual, semi-structured telephone interviews with 12 ANAI adults who smoke, 12 adult family members, and 13 Alaska Tribal Health System stakeholders statewide between November 2022-March 2023. Through content analysis, we explored intervention receptivity, incentive preferences, culturally aligned recruitment and intervention messaging, and future implementation needs. RESULTS: Participants were receptive to the intervention. Involving a family member was viewed as novel and aligned with ANAI cultural values of commitment to community and familial interdependence. Major themes included choosing a family member who is supportive and understanding, keeping materials positive and encouraging, and offering cash and non-cash incentives for family members to choose (e.g., fuel, groceries, activities). Participants indicated that messaging should emphasize family collaboration and that cessation resources and support tips should be provided. Stakeholders also reinforced that program materials should encourage the use of other existing evidence-based cessation therapies (e.g., nicotine replacement, counseling). CONCLUSIONS: Adaptations, grounded in ANAI cultural strengths were made to the intervention and recruitment materials based on participant feedback. Next steps include a beta-test for feasibility and a randomized controlled trial for efficacy. IMPLICATIONS: This is the first study to design and adapt a financial incentives intervention promoting smoking cessation among Alaska Native or American Indian (ANAI) peoples and the first to involve the family system. Feedback from this formative work was used to develop a meaningful family-level incentive structure with ANAI people who smoke and family members and ensure intervention messaging is supportive and culturally aligned. The results provide qualitative knowledge that can inform future family-based interventions with ANAI communities, including our planned randomized controlled trial of the intervention.

Facebook Intervention to Connect Alaska Native People With Resources and Support to Quit Smoking: CAN Quit Pilot Randomized Controlled Trial.

INTRODUCTION: There is some evidence that social media interventions can promote smoking cessation. This randomized controlled pilot study is the first to evaluate the feasibility and potential efficacy of a Facebook smoking cessation intervention among Alaska Native (AN) adults. AIMS AND METHODS: Recruitment and data collection occurred from December 2019 to March 2021. Participants were recruited statewide in Alaska using Facebook advertisements with a targeted sample of 60 enrolled. Participants were stratified by gender, age, and rural or urban residence and randomly assigned to receive referral resources on evidence-based cessation treatments (EBCTs) (control, n = 30) or these resources plus a 3-month, closed (private), culturally tailored, Facebook group (intervention, n = 31) that connected participants to EBCT resources and was moderated by two Alaska Native Trained Tobacco Specialists. Assessments were conducted online post-randomization at 1, 3, and 6 months. Outcomes were feasibility (recruitment, retention, and intervention engagement), self-reported use of EBCTs, and biochemically confirmed seven-day point-prevalence smoking abstinence. RESULTS: Of intervention participants, 90% engaged (eg posted, commented) more than once. Study retention was 57% at 6 months (no group differences). The proportion utilizing EBCTs was about double for intervention compared with the control group participants at 3 and 6 months. Smoking abstinence was higher for intervention than control participants at 3 months (6.5% vs. 0%, p = .16) but comparable at 6 months (6.4% vs. 6.7%, p = .97). CONCLUSIONS: While additional research is needed to promote long-term cessation, this pilot trial supports recruitment feasibility during the Coronavirus Disease 2019 (COVID-19) pandemic, consumer uptake, and a signal for intervention efficacy on the uptake of cessation treatment and short-term smoking abstinence. IMPLICATIONS: This study is the first evaluation of a social media intervention for smoking cessation among Indigenous people. We learned that statewide Facebook recruitment of AN adults who smoke was feasible and there was a signal for the efficacy of a Facebook intervention on the uptake of EBCT and short-term (3 months) biochemically verified smoking abstinence. Clinically, social media platforms may complement current care models by connecting AN individuals and others living in hard-to-reach communities to cessation treatment resources.

Alaska Native Parents' Decision-Making About Food, Beverages, and Screen Time for Young Children: Formative Insights From the "Got Neqpiaq?" Project.

With rising childhood obesity rates, ensuring children adopt healthy habits early is imperative. Given the unique context for Alaska Native families living in rural remote communities, who are concurrently experiencing changes in traditional practices, we investigated what impacts parents' decisions as they relate to daily living before revising a preschool curriculum focused on healthy habits. The objective of this study was to explore factors influencing parents' decisions about their children's foods, beverages, and activities. In focus group discussions with AN parents of young children across 12 communities, we asked about meals, traditional foods, beverages, physical activity, and screen time. All sessions were recorded, transcribed, and analyzed using open and selective coding to allow the most important themes to emerge. As parents discussed how they make decisions, several trends emerged related to adults' and children's food and beverage preferences; the impact of adult modeling on children; and how convenience, seasonality, access, and a reluctance to engage in conflict all impact decision-making. Parents and other community members shared important perspectives on exposing children to traditional subsistence foods and activities and passing important traditional knowledge to them at an early age. These perspectives will form the basis for preschool curricula in these communities.

Lessons Learned From Beta-Testing a Facebook Group Prototype to Promote Treatment Use in the "Connecting Alaska Native People to Quit Smoking" (CAN Quit) Study.

Social media provides an effective tool to reach, engage, and connect smokers in cessation efforts. Our team developed a Facebook group, CAN Quit (Connecting Alaska Native People to Quit smoking), to promote use of evidence-based smoking cessation resources for Alaska Native people living in Alaska, which are underused despite their effectiveness. Often separated by geography and climate, Alaska Native people prefer group-based approaches for tobacco cessation that support their culture and values. Such preferences make Alaska Native people candidates for social media-based interventions that promote connection. This viewpoint discusses the steps involved and lessons learned in building and beta-testing our Facebook group prototype, which will then be evaluated in a pilot randomized controlled trial. We describe the process of training moderators to facilitate group engagement and foster community, and we describe how we developed and tested our intervention prototype and Facebook group. All parts of the prototype were designed to facilitate use of evidence-based cessation treatments. We include recommendations for best practices with the hope that lessons learned from the CAN Quit prototype could provide a model for others to create similar platforms that benefit Alaska Native and American Indian people in the context of smoking cessation.

Life-history theory provides a framework for detecting resource limitation: a test of the Nutritional Buffer Hypothesis.

For ungulates and other long-lived species, life-history theory predicts that nutritional reserves are allocated to reproduction in a state-dependent manner because survival is highly conserved. Further, as per capita food abundance and nutritional reserves decline (i.e., density dependence intensifies), reproduction and recruitment become increasingly sensitive to weather. Thus, the degree to which weather influences vital rates should be associated with proximity to nutritional carrying capacity-a notion that we refer to as the Nutritional Buffer Hypothesis. We tested the Nutritional Buffer Hypothesis using six moose (Alces alces) populations that varied in calf recruitment (33-69 calves/100 cows). We predicted that populations with high calf recruitment were nutritionally buffered against the effects of unfavorable weather, and thus were below nutritional carrying capacity. We applied a suite of tools to quantify habitat and nutritional condition of each population and found that increased browse condition, forage quality, and body fat were associated with increased pregnancy and calf recruitment, thereby providing multiple lines of evidence that declines in calf recruitment were underpinned by resource limitation. From 2001 to 2015, recruitment was more sensitive to interannual variation in weather (e.g., winter severity, drought) and plant phenology (e.g., duration of spring) for populations with reduced browse condition, forage quality, and body fat, suggesting these populations lacked the nutritional reserves necessary to buffer demographic performance against the effects of unfavorable weather. Further, average within-population calf recruitment was determined by regional climatic variation, suggesting that the pattern of reduced recruitment near the southern range boundary of moose stems from an interaction between climate and resource limitation. When coupled with information on habitat, nutrition, weather, and climate, life-history theory provides a framework to estimate nutritional limitation, proximity to nutritional carrying capacity, and impacts of climate change for ungulates.

Developing a Social Media Intervention to Connect Alaska Native People Who Smoke with Resources and Support to Quit Smoking: The Connecting Alaska Native Quit Study.

BACKGROUND: Face-to-face tobacco cessation has had limited reach and efficacy in Alaska Native (AN) communities. We describe our two-phased approach to develop content for Connecting Alaska Native People to Quit Smoking, a Facebook group intervention to reduce barriers to evidence-based smoking cessation treatment for AN people in Alaska. METHODS: Phase 1 included semi-structured telephone interviews with 30 AN people who smoke and ten stakeholders. They provided feedback on existing content from the Centers for Disease Control and Prevention Tips campaign and AN digital stories. Phase 2 included an online survey with a new group of 40 AN smokers who provided feedback on existing content via a measure of perceived effectiveness and cultural relevance. RESULTS: Phase I results revealed participants evaluated content based upon story strength, relevance to AN culture, emotional appeal, relatability to AN people, and favorite video. No single posting was rated highly across all themes. All perceived effectiveness (PE) and cultural relevance median scores fell between 3.5 and 4.4 (range 1-5). PE scores varied across participant demographic groups. CONCLUSIONS: Content embodying characteristics perceived to be most appealing, effective, and culturally relevant were selected for the private Facebook group content library with refinements made to incorporate images of AN people engaged in AN activities. PE scores indicate a need for a wide variety of content that moderators could pull from when conducting the intervention. IMPLICATIONS: Social media content targeting specific population sectors, such as American Indian/AN people for tobacco cessation needs to be culturally tailored. Our approach provides a model others can follow to determine what is appealing, relevant, and effective messaging. CLINICAL TRIAL REGISTRATION: NCT03645941.

Alaska Native Elders' perspectives on dietary patterns in rural, remote communities.

BACKGROUND: Given the increasing rates of childhood obesity in Alaska Native children and the understanding that the most effective interventions are informed by and reflect the cultural knowledge of the community in which they are implemented, this project sought to gather the wisdom of local Yup'ik and Cup'ik Elders in the Yukon-Kuskokwim region of Alaska around how to maintain a healthy diet and active lifestyle. METHODS: Perspectives were sought through the use of semi-structured focus groups, which were completed in person in twelve communities. All conversations were recorded, translated, transcribed, and analyzed using a qualitative approach, where key themes were identified. RESULTS: Elders provided a clear and consistent recollection of what their life looked like when they were young and expressed their perspectives related to maintaining a healthy and traditional lifestyle. The key themes the Elders discussed included an emphasis on the nutritional and cultural benefits of traditional foods; concerns around changing dietary patterns such as the consumption of processed foods and sugar sweetened beverages; and concerns on the time and use of screens. Elders also expressed a desire to help younger generations learn traditional subsistence practices. CONCLUSIONS: The risk of obesity in Alaska Native children is high and intervention efforts should be grounded in local knowledge and values. The perspectives from Yup'ik and Cup'ik Elders in the Yukon-Kuskokwim Delta area of Alaska provide a better understanding on local views of how to maintain a healthy diet, physical activities, and traditional values.

Diet and the Human Gut Microbiome: An International Review.

This review summarizes the key results of recently published studies on the effects of dietary change and nutritional intervention on the human microbiome from around the world, focusing on the USA, Canada, Europe, Asia, and Africa. It first explores mechanisms that might explain the ability of fiber-rich foods to suppress the incidence and mortality from westernized diseases, notably cancers of the colon, breast, liver, cardiovascular, infectious, and respiratory diseases, diabetes, and obesity (O'Keefe in Lancet Gastroenterol Hepatol 4(12):984-996, 2019; Am J Clin Nutr 110:265-266, 2019). It summarizes studies from Africa which suggest that disturbance of the colonic microbiome may exacerbate chronic malnutrition and growth failure in impoverished communities and highlights the importance of breast feeding. The American section discusses the role of the microbiome in the swelling population of patients with obesity and type 2 diabetes and examines the effects of race, ethnicity, geography, and climate on microbial diversity and metabolism. The studies from Europe and Asia extoll the benefits of whole foods and plant-based diets. The Asian studies examine the worrying changes from low-fat, high-carbohydrate diets to high-fat, low-carbohydrate ones and the increasing appearance of westernized diseases as in Africa and documents the ability of high-fiber traditional Chinese diets to reverse type 2 diabetes and control weight loss. In conclusion, most of the studies reviewed demonstrate clear changes in microbe abundances and in the production of fermentation products, such as short-chain fatty acids and phytochemicals following dietary change, but the significance of the microbiota changes to human health, with the possible exception of the stimulation of butyrogenic taxa by fiber-rich foods, is generally implied and not measured. Further studies are needed to determine how these changes in microbiota composition and metabolism can improve our health and be used to prevent and treat disease.

Lack of in-home piped water and reported consumption of sugar-sweetened beverages among adults in rural Alaska.

OBJECTIVE: To assess whether a community water service is associated with the frequency of sugar-sweetened beverages (SSB) consumption, obesity, or perceived health status in rural Alaska. DESIGN: We examined the cross-sectional associations between community water access and frequency of SSB consumption, body mass index categories, and perceived health status using data from the 2013 and 2015 Alaska Behavioral Risk Factor Surveillance System (BRFSS). Participants were categorized by zip code to 'in-home piped water service' or 'no in-home piped water service' based on water utility data. We evaluated the univariable and multivariable (adjusting for age, household income and education) associations between water service and outcomes using log-linear survey-weighted generalized linear models. SETTING: Rural Alaska, USA. SUBJECTS: Eight hundred and eighty-seven adults, aged 25 years and older. RESULTS: In unadjusted models, participants without in-home water reported consuming SSB more often than participants with in-home water (1·46, 95 % CI: 1·06, 2·00). After adjustment for potential confounders, the effect decreased but remained borderline significant (1·29, 95 % CI: 1·00, 1·67). Obesity was not significantly associated with water service but self-reported poor health was higher in those communities without in-home water (1·63, 95 % CI: 1·05, 2·54). CONCLUSIONS: Not having access to in-home piped water could affect behaviours surrounding SSB consumption and general perception of health in rural Alaska.

Fiber, Fat, and Colorectal Cancer: New Insight into Modifiable Dietary Risk Factors.

PURPOSE OF REVIEW: To review recent data on the role and interactions of fiber and fat as dietary risk factors associated with colorectal cancer (CRC) risk in humans. RECENT FINDINGS: Fiber intake shows convincing and linear dose-response negative correlation with CRC risk. Dietary fiber stimulates butyrogenic activity of the gut microbiota, providing high amounts of butyrate that shows extensive anti-neoplastic effects. A high-fat diet promotes CRC risk through stimulated bile acid metabolism, facilitating bile acid conversion by the gut microbiota to tumor-promoting deoxycholic acid. Comprehensive interactions of these microbial metabolites are likely to underlie mechanisms driving diet-dependent CRC risk in different populations, but require further experimental investigation. Dietary fiber and fat shape the composition and metabolic function of the gut microbiota, resulting in altered amounts of butyrate and deoxycholic acid in the colon. Fiber supplementation and restriction of fat intake represent promising strategies to reduce CRC risk in healthy individuals.

Correlation of Adherence by Pill Count, Self-report, MEMS and Plasma Drug Levels to Treatment Response Among Women Receiving ARV Therapy for PMTCT in Kenya.

Success of antiretroviral therapy depends on adherence to effective treatment. We evaluated four adherence methods and their correlation with immunological and virologic response among women receiving PMTCT. Univariable and multivariable analyses were used to assess how adherence by pill count (n = 463), self-report (n = 463), MEMS (n = 129) and plasma drug level (n = 89) was associated with viral load suppression within a 6 months period. Longitudinal analysis was performed to determine the correlation of CD4 cell count with each measure of adherence. For all measures of adherence, sustained viral suppression was less likely for participants in the lowest category of adherence. Although CD4 cell count increased substantially over time, there was no significant association with adherence by the methods. Multiple strategies can be used successfully to monitor treatment adherence. Persons with ≥95% adherence by any method used in this study were more likely to have a favorable treatment outcome.

Perceived risks and reasons to smoke cigarettes during pregnancy among Alaska native women.

OBJECTIVE: The purpose of this study was to explore perceptions of the risks of smoking and reasons Alaska Native women give for smoking during pregnancy. DESIGN: A total of 118 women (54 smokers, 64 non-smokers) enrolled in a biomarker study and completed a baseline interview asking about their concerns regarding tobacco use while pregnant and reasons why pregnant women might smoke during pregnancy. Responses were collapsed into six categories of perceived risks of smoking and eight categories of reasons to smoke during pregnancy. RESULTS: The majority of both pregnant non-smokers and smokers (72.6% and 60.4%) agreed that smoking during pregnancy could negatively impact the health of their baby. However, non-smokers were more likely than smokers (77.4% vs. 58.5%) to view smoking during pregnancy as a risk factor for the baby's development (p = .029). Both non-smokers and smokers identified addiction as a reason for smoking during pregnancy (82.8% and 63%); however, non-smokers were more likely than smokers to state this was a reason for use (p = .015). Seventy-three percent of the entire sample reported a reason to smoke in pregnancy was to help manage negative affect. CONCLUSION: Results from this work may be helpful in advancing research by identifying targets for intervention specific to Alaska Native women receiving prenatal care in Anchorage, Alaska.

Developing a Biomarker Feedback Intervention to Motivate Smoking Cessation During Pregnancy: Phase II MAW Study.

INTRODUCTION: The prevalence of smoking during pregnancy for Alaska Native (AN) women is more than triple that of non-Native Alaska women. In this qualitative study, we solicited input from AN women and others to determine how best to present findings from an earlier study demonstrating a strong correlation between biomarkers for maternal smoking (cotinine) and neonatal exposure to a tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) to motivate cessation. METHODS: We developed a brochure incorporating generalized biomarker information. Using in-depth individual interviews with pregnant and postpartum AN women and partners/family members, we explored applicability and acceptability of the information. Postpartum women, who had participated in the earlier correlation study, additionally received their individual biomarker results. We assessed whether being presented general or individual biomarker information would motivate cessation using content analysis. RESULTS: We conducted 39 interviews: 16 pregnant women, 12 postpartum women, and 11 partners/family members. Overall, participants agreed the biomarker information was new, but understandable as presented. Postpartum women shared that learning their personal results inspired them to want to quit or cut back smoking while pregnant women indicated the generalized correlation information was less helpful in motivating cessation. CONCLUSION: Generalized information about fetal exposure to carcinogens may be more effective in motivating pregnant women to quit smoking when combined with individual cotinine testing. IMPLICATIONS: Using feedback from this study, we refined and are currently evaluating an intervention incorporating generalized correlation information from Phase I and cotinine testing to determine its effectiveness in motivating smoking cessation among pregnant AN women.

Prevalence and dynamics of the K65R drug resistance mutation in HIV-1-infected infants exposed to maternal therapy with lamivudine, zidovudine and either nevirapine or nelfinavir in breast milk.

BACKGROUND: K65R is a relatively rare drug resistance mutation (DRM) selected by the NRTIs tenofovir, didanosine, abacavir and stavudine and confers cross-resistance to all NRTIs except zidovudine. Selection by other NRTIs is uncommon. OBJECTIVES: In this study we investigated the frequency of emergence of the K65R mutation and factors associated with it in HIV-1-infected infants exposed to low doses of maternal lamivudine, zidovudine and either nevirapine or nelfinavir ingested through breast milk, using specimens collected from the Kisumu Breastfeeding Study. METHODS: Plasma specimens with viral load ≥1000 copies/mL collected from HIV-infected infants at 0-1, 2, 6, 14, 24 and 36 weeks of age and maternal samples at delivery were tested for HIV drug resistance using Sanger sequencing of the polymerase gene. Factors associated with K65R emergence were assessed using Fisher's exact test and the Wilcoxon rank-sum test. RESULTS: K65R was detected in samples from 6 of the 24 infants (25%) who acquired HIV-1 infection by the age of 6 months. K65R emerged in half of the infants by 6 weeks and in the rest by 14 weeks of age. None of the mothers at delivery or the infants with a positive genotype at first time of positivity had the K65R mutation. Infants with K65R had low baseline CD4 cell counts (P = 0.014), were more likely to have DRMs earlier (≤6 weeks versus ≥14 weeks, P = 0.007) and were more likely to have multiclass drug resistance (P = 0.035). M184V was the most common mutation associated with K65R emergence. K65R had reverted by 3 months after cessation of breastfeeding. CONCLUSIONS: A high rate of K65R emergence may suggest that ingesting low doses of lamivudine via breast milk could select for this mutation. The presence of this mutation may have a negative impact on future responses to NRTI-based ART. More in vitro studies are, however, needed to establish the molecular mechanism for this selection.

Anaemia in HIV-infected pregnant women receiving triple antiretroviral combination therapy for prevention of mother-to-child transmission: a secondary analysis of the Kisumu breastfeeding study (KiBS).

OBJECTIVE: The prevalence of anaemia during pregnancy is estimated to be 35-75% in sub-Saharan Africa and is associated with an increased risk of maternal mortality. We evaluated the frequency and factors associated with anaemia in HIV-infected women undergoing antiretroviral (ARV) therapy for prevention of mother-to-child transmission (PMTCT) enrolled in The Kisumu Breastfeeding Study 2003-2009. METHODS: Maternal haematological parameters were monitored from 32 to 34 weeks of gestation to 2 years post-delivery among 522 enrolled women. Clinical and laboratory assessments for causes of anaemia were performed, and appropriate management was initiated. Anaemia was graded using the National Institutes of Health Division of AIDS 1994 Adult Toxicity Tables. Data were analysed using SAS software, v 9.2. The Wilcoxon two-sample rank test was used to compare groups. A logistic regression model was fitted to describe the trend in anaemia over time. RESULTS: At enrolment, the prevalence of any grade anaemia (Hb < 9.4 g/dl) was 61.8%, but fell during ARV therapy, reaching a nadir (7.4%) by 6 months post-partum. A total of 41 women (8%) developed severe anaemia (Hb < 7 g/dl) during follow-up; 2 (4.9%) were hospitalised for blood transfusion, whereas 3 (7.3%) were transfused while hospitalised (for delivery). The greatest proportion of severe anaemia events occurred around delivery (48.8%; n = 20). Anaemia (Hb ≥ 7 and < 9.4 g/dl) at enrolment was associated with severe anaemia at delivery (OR 5.87; 95% CI: 4.48, 7.68, P < 0.01). Few cases of severe anaemia coincided with clinical malaria (24.4%; n = 10) and helminth (7.3%; n = 3) infections. CONCLUSION: Resolution of anaemia among most participants during study follow-up was likely related to receipt of ARV therapy. Efforts should be geared towards addressing common causes of anaemia in HIV-infected pregnant women, prioritising initiation of ARV therapy and management of peripartum blood loss.

Fetal Exposure to Carcinogens With Tobacco Use in Pregnancy: Phase 1 MAW Study Findings.

INTRODUCTION: The high prevalence of smoking and smokeless tobacco (ST) use during pregnancy in Alaska Native (AN) women is concerning due to the detrimental effects of these products to the mother and the developing fetus. We sought to correlate maternal cotinine levels with fetal exposure to a tobacco-specific carcinogen to incorporate in a biomarker feedback intervention to motivate tobacco cessation during pregnancy. METHODS: Demographic and tobacco use data were collected from a convenience sample of pregnant AN smokers, ST users, and non-users. Maternal and neonatal urine were collected at delivery. Maternal urine cotinine and neonatal urine total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL, a tobacco-specific carcinogen) levels in smokers and ST users were analyzed and their correlations determined by Spearman correlation coefficients. RESULTS: During 2012-2014, we enrolled 64 non-users, 54 smokers, and 30 ST (20 homemade iqmik; 10 commercial ST) users (n = 148). Analyses of paired maternal-infant urine samples obtained for 36 smokers demonstrated a moderate to strong correlation (r = 0.73, P < .001) between maternal cotinine and infant NNAL levels. The correlation was not significant for 25 iqmik users (r = 0.36, P = .17) or 9 commercial ST users (r = 0.60, P = .09). No analysis was conducted for 55 non-users with cotinine and NNAL levels < limits of quantification. CONCLUSIONS: There is a moderate to strong correlation between maternal smoking and fetal exposure to the tobacco-specific carcinogen NNAL. IMPLICATIONS: The correlation between maternal smoking and fetal carcinogen exposure may provide an education tool to help motivate smoking cessation among pregnant AN women. Further investigation is warranted to determine correlations between maternal commercial ST and iqmik use and neonatal NNAL.

Registered Nurses Leading Innovative Changes

As innovators, all registered nurses (RNs) act as agents of change to drive processes and policy and leverage technology to prove better, more affordable care for individuals and the community. The authors consider examples of RNs leading innovative ideas and practices to create new knowledge; develop healthcare policies and practices; improve the quality of care; and advance health information technology. This article describes a number of key innovation goals identified by the American Nurses Association Professional Issues Panel, Barriers to RN Scope of Practice, discusses relevant literature related to overcoming barriers to innovation, and identifies recommendations for leading innovative change to achieve innovation goals.

Registered Nurses as Caregivers: Influencing the System as Patient Advocates

Registered Nurses (RNs) influence the health of individual patients and populations. RNs provide the most value for the healthcare system when they work collaboratively with other healthcare team members, work to their full scope of practice, and when they are engaged and accountable. In 2011, the Institute of Medicine report on the future of nursing made the call to achieve the full value of nursing care. Creation of this future state requires both a vision of the "to be" as well as removal of existing barriers. In this article, we present a description of this future state in the context of a team based culture that utilizes collaboration to achieve the full scope of practice, accountability to deliver healthcare based on a discrete body of knowledge, and accountability to provide value and measure effectiveness of nursing care. This proposed future vision focuses on patient advocacy for nurses working in healthcare systems. Barriers that currently exist, such as overlaps in professional scopes of practice, organizational policy and structure, and a lack of the ability to grant privileges to nurses based upon their education and skills are discussed. We offer recommendations to remove barriers and contribute to creation of a new future state of nursing, and conclude that the removal of barriers to inhibit the fullest scope of nursing practice will continue to require focus in purpose and persistence in action.

Registered Nurses as Professionals, Advocates, Innovators, and Collaborative Leaders: Executive Summary

This article concludes a series that described work completed by the American Nurses Association (ANA) Barriers to RN Scope of Practice Professional Issues Panel (Panel). The Panel has summarized the roles of the registered nurse (RN) as professional, advocate, innovator, and collaborative leader. As professionals, RNs are accountable for their own educational development, growth of their own practice, and execution of their own professional role. As advocates, RNs provide direct and indirect care focused on the achievement of optimal health. As innovators, RNs act as agents of change in driving processes and policy and leveraging technology. As collaborative leaders, RNs lead within the professional practice setting with state-specific nurse practice acts, a defined scope of practice, and nurse-led initiatives. In this article, Panel members describe their methodology, offer role definitions and recommendations, and provide individual recommendations for RNs to remove barriers and practice to the full extent of their scope of practice. We conclude with some future considerations.

Effects of climate and plant phenology on recruitment of moose at the southern extent of their range.

Climate plays a fundamental role in limiting the range of a species, is a key factor in the dynamics of large herbivores, and is thought to be involved in declines of moose populations in recent decades. We examined effects of climate and growing-season phenology on recruitment (8-9 months old) of young Shiras moose (Alces alces shirasi) over three decades, from 18 herds, across a large geographic area encompassing much of the southern extent of their range. Recruitment declined in 8 of 18 herds during 1980-2009, whereas others did not exhibit a temporal trend (none showed a positive trend). During those three decades, seasonal temperatures increased, spring-summer precipitation decreased, and spring occurred earlier, became shorter in duration, and green-up occurred faster. Recruitment was influenced negatively by warm temperatures during the year before young were born, but only for herds with declining recruitment. Dry spring-summers of the previous year and rapid rates of spring green-up in the year of birth had similar negative influences across declining and stable herds. Those patterns indicate both direct (year(t)) and delayed (year(t-1)) effects of weather and plant phenology on recruitment of young, which we hypothesize was mediated through effects on maternal nutritional condition. Suppressed nutrition could have been induced by (1) increased thermoregulatory costs associated with warming temperatures and (2) shortened duration of availability of high-quality forage in spring. Progressive reductions in net energetic gain for species that are sensitive to climate may continue to hamper individual fitness and population dynamics.