Allostery in the nitric oxide dioxygenase mechanism of flavohemoglobin.

The substrates O2 and NO cooperatively activate the NO dioxygenase function of Escherichia coli flavohemoglobin. Steady-state and transient kinetic measurements support a structure-based mechanistic model in which O2 and NO movements and conserved amino acids at the E11, G8, E2, E7, B10, and F7 positions within the globin domain control activation. In the cooperative and allosteric mechanism, O2 migrates to the catalytic heme site via a long hydrophobic tunnel and displaces LeuE11 away from the ferric iron, which forces open a short tunnel to the catalytic site gated by the ValG8/IleE15 pair and LeuE11. NO permeates this tunnel and leverages upon the gating side chains triggering the CD loop to furl, which moves the E and F-helices and switches an electron transfer gate formed by LysF7, GlnE7, and water. This allows FADH2 to reduce the ferric iron, which forms the stable ferric-superoxide-TyrB10/GlnE7 complex. This complex reacts with internalized NO with a bimolecular rate constant of 1010 M-1 s-1 forming nitrate, which migrates to the CD loop and unfurls the spring-like structure. To restart the cycle, LeuE11 toggles back to the ferric iron. Actuating electron transfer with O2 and NO movements averts irreversible NO poisoning and reductive inactivation of the enzyme. Together, structure snapshots and kinetic constants provide glimpses of intermediate conformational states, time scales for motion, and associated energies.

Retroviral prototype foamy virus intasome binding to a nucleosome target does not determine integration efficiency.

Retroviral integrases must navigate host DNA packaged as chromatin during integration of the viral genome. Prototype foamy virus (PFV) integrase (IN) forms a tetramer bound to two viral DNA (vDNA) ends in a complex termed an intasome. PFV IN consists of four domains: the amino terminal extension domain (NED), amino terminal domain (NTD), catalytic core domain (CCD), and carboxyl terminal domain (CTD). The domains of the two inner IN protomers have been visualized, as well as the CCDs of the two outer IN protomers. However, the roles of the amino and carboxyl terminal domains of the PFV intasome outer subunits during integration to a nucleosome target substrate are not clear. We used the well-characterized 601 nucleosome to assay integration activity as well as intasome binding. PFV intasome integration to 601 nucleosomes occurs in clusters at four independent sites. We find that the outer protomer NED and NTD domains have no significant effects on integration efficiency, site selection, or binding. The CTDs of the outer PFV intasome subunits dramatically affect nucleosome binding but have little effect on total integration efficiency. The outer PFV IN CTDs did significantly alter the integration efficiency at one site. Histone tails also significantly affect intasome binding, but have little impact on PFV integration efficiency or site selection. These results indicate that binding to nucleosomes does not correlate with integration efficiency and suggests most intasome-binding events are unproductive.

Development of nurse practitioner metaspecialty clinical practice standards: A national sequential mixed methods study.

AIM: To achieve profession-wide consensus on clinical practice standards for six broad Australian nurse practitioner specialty areas (termed metaspecialties). DESIGN: Sequential mixed methods with initial interpretive study (Interpretive Phase) followed by modified three-round Delphi study (Survey Phase). METHODS: Participants from all Australian jurisdictions were recruited. Main eligibility criterion was current endorsement as a nurse practitioner for 12 or more months. Interpretive Phase comprised in-depth interviews of purposeful sample of nurse practitioners to identify clinical care activities and practice processes. Six sets of draft clinical practice standards relevant to six previously identified metaspecialties were developed. Outcome informed Round 1 of Survey Phase (six nested web-based Delphi surveys), with draft standards reviewed profession-wide. Responses comprised scoring using Likert scales to calculate content validity indexes for individual standards with qualitative responses supporting decision-making. For Rounds 2 and 3, participants rated relevancy of original or revised standards after consideration of individual and group feedback. The study was conducted 2014-2017. RESULTS: Interpretive Phase: Analysis of interview data with 16 nurse practitioners provided 75 draft standards. Survey Phase: 221 nurse practitioners completed Round 1 (20% of then eligible Australian nurse practitioners). Weighted respondent retention was 92%. Seventy-three standards were validated, with final content validity indices of 92-100%. Scale-level indices were 98%, strongly validating metaspecialty taxonomy. CONCLUSION: A research-derived, professionally endorsed suite of nurse practitioner clinical practice standards was developed. This provides a broad clinical learning structure with metaspecialties guiding nurse practitioner student clinical education. IMPACT: The clinical practice standards and metaspecialty taxonomy strengthen nurse practitioner clinical education and professional development nationally and internationally. These novel study methods and findings are applicable to advanced specialty roles in other health professions.

Cost-effectiveness of an Environmental Cleaning Bundle for Reducing Healthcare-associated Infections.

BACKGROUND: Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016-2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs. METHODS: A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices. RESULTS: Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices. CONCLUSIONS: A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.

Hospital Staffing and Health Care-Associated Infections: A Systematic Review of the Literature.

BACKGROUND: Previous literature has linked the level and types of staffing of health facilities to the risk of acquiring a health care-associated infection (HAI). Investigating this relationship is challenging because of the lack of rigorous study designs and the use of varying definitions and measures of both staffing and HAIs. METHODS: The objective of this study was to understand and synthesize the most recent research on the relationship of hospital staffing and HAI risk. A systematic review was undertaken. Electronic databases MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for studies published between January 1, 2000, and November 30, 2015. RESULTS: Fifty-four articles were included in the review. The majority of studies examined the relationship between nurse staffing and HAIs (n = 50, 92.6%) and found nurse staffing variables to be associated with an increase in HAI rates (n = 40, 74.1%). Only 5 studies addressed non-nurse staffing, and those had mixed results. Physician staffing was associated with an increased HAI risk in 1 of 3 studies. Studies varied in design and methodology, as well as in their use of operational definitions and measures of staffing and HAIs. CONCLUSION: Despite the lack of consistency of the included studies, overall, the results of this systematic review demonstrate that increased staffing is related to decreased risk of acquiring HAIs. More rigorous and consistent research designs, definitions, and risk-adjusted HAI data are needed in future studies exploring this area.

Mapping workforce configuration and operational models in Australian emergency departments: a national survey.

Objective Hospital emergency departments (ED) in Australia and internationally have been experiencing increased demand, resulting in reduced hospital quality, impaired access and adverse health outcomes. Effective evaluation of new ED service models and their effect on outcomes is reliant on baseline measures of the staffing configuration and organisational characteristics of the EDs being studied. The aim of the present study was to comprehensively measure these variables in Australian EDs. Methods Australian hospital EDs with 24-h medical and nursing cover were identified and invited to participate in the study. Telephone interviews were conducted with nursing or medical department managers to collect data related to hospital characteristics, ED workforce and training and ED service and operational models. Results Surveys were completed in 87% of the population sample (n=135). Metropolitan EDs were significantly more likely to retain higher full-time equivalents (FTEs) in several medical (staff specialist, registrar, resident and intern) and nursing (nurse practitioner (NP), nurse educator, nurse unit manager and registered nurse) positions. NPs were employed by 52% of Australian EDs overall, but this ranged from 40% to 75% depending on jurisdiction. The most commonly used operational models were FastTrack teams (72% of EDs), short-stay/observational unit (59%) and patient liaison models for aged care (84%) and mental health (61%). EDs that employed NPs were significantly more likely to use FastTrack (P=0.002). Allied health services most frequently available within these EDs were radiology (60%), social work (69%), physiotherapy (70%) and pharmacy (65%). Conclusions The present study has established a baseline measure of the staffing configuration and organisational characteristics of Australian EDs. What is known about the topic? EDs are overcrowded due, in part, to the combined effect of increased service demand and access block. Innovative service and workforce models have been implemented by health departments aiming to improve service and performance. National uptake of these service and workforce innovations is unknown. What does this paper add? The present study is the most comprehensive to date profiling Australian EDs covering hospital characteristics, workforce configuration, operational models and NP service patterns and practice. What are the implications for practitioners? Information from the present study will assist health service planners to evaluate workforce and service reform models, and to monitor trends in emergency service development.

The use of advanced web-based survey design in Delphi research.

AIM: A discussion of the application of metadata, paradata and embedded data in web-based survey research, using two completed Delphi surveys as examples. BACKGROUND: Metadata, paradata and embedded data use in web-based Delphi surveys has not been described in the literature. The rapid evolution and widespread use of online survey methods imply that paper-based Delphi methods will likely become obsolete. Commercially available web-based survey tools offer a convenient and affordable means of conducting Delphi research. Researchers and ethics committees may be unaware of the benefits and risks of using metadata in web-based surveys. DESIGN: Discussion paper. DATA SOURCES: Two web-based, three-round Delphi surveys were conducted sequentially between August 2014 - January 2015 and April - May 2016. Their aims were to validate the Australian nurse practitioner metaspecialties and their respective clinical practice standards. Our discussion paper is supported by researcher experience and data obtained from conducting both web-based Delphi surveys. IMPLICATIONS FOR NURSING: Researchers and ethics committees should consider the benefits and risks of metadata use in web-based survey methods. Web-based Delphi research using paradata and embedded data may introduce efficiencies that improve individual participant survey experiences and reduce attrition across iterations. Use of embedded data allows the efficient conduct of multiple simultaneous Delphi surveys across a shorter timeframe than traditional survey methods. CONCLUSION: The use of metadata, paradata and embedded data appears to improve response rates, identify bias and give possible explanation for apparent outlier responses, providing an efficient method of conducting web-based Delphi surveys.

Consensus on an Australian Nurse practitioner specialty framework using Delphi methodology: results from the CLLEVER 2 study.

AIM: The aim of this study was to achieve profession-wide consensus on an Australian nurse practitioner specialty framework. BACKGROUND: Since its introduction in 1998, the Australian nurse practitioner profession has grown to over 1300 endorsed practitioners, representing over 50 different specialties. To complement better a generalist learning and teaching framework with specialist clinical education, prior research proposed a broad framework of Australian nurse practitioner specialty areas termed metaspecialties. DESIGN: This study employed an online three-round modified Delphi method. METHOD: Recruitment using purposive sampling and snowballing techniques identified an eligible sample from a population of nurse practitioners with at least 12 months' postendorsement experience (n = 966). Data were collected using online survey software from September 2014-January 2015 and analysed using descriptive statistics and content analysis. The Content Validity Index and McNemar's Test for Change were used to determine consensus on the nurse practitioner metaspecialties. RESULTS: One-fifth of the total eligible population completed the study. Participants achieved high consensus on four metaspecialties, including: Emergency and acute care, primary health care, child and family health care and mental health care. Two metaspecialties did not achieve consensus and require further investigation. CONCLUSION: A large sample of nurse practitioners achieved consensus on an Australian metaspecialty framework, increasing the likelihood of widespread acceptance across the profession. This technique may be appropriate for use in jurisdictions with smaller populations of nurse practitioners. Ongoing research is needed to re-evaluate the metaspecialties as the profession grows.

Transition from an open-plan to a two-cot neonatal intensive care unit: a participatory action research approach.

AIMS AND OBJECTIVES: To facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. BACKGROUND: In 2012, an Australian regional neonatal intensive care unit transitioned from an open-plan to a two-cot neonatal intensive care unit design. Research has reported single- and small-room neonatal intensive care unit design may negatively impact on the distances nurses walk, reducing the time they spend providing direct neonatal care. Studies have also reported nurses feel isolated and need additional support and education in such neonatal intensive care units. Staff highlighted their concerns regarding the impact of the new design on workflow and clinical practice. DESIGN: A participatory action research approach. METHODS: A participatory action group titled the Change and Networking Group collaborated with staff over a four-year period (2009-2013) to facilitate the transition. The Change and Networking Group used a collaborative, cyclical process of planning, gathering data, taking action and reviewing the results to plan the next action. Data sources included meeting and workshop minutes, newsletters, feedback boards, subgroup reports and a staff satisfaction survey. RESULTS: The study findings include a description of (1) how the participatory action research cycles were used by the Change and Networking Group: providing examples of projects and strategies undertaken; and (2) evaluations of participatory action research methodology and Group by neonatal intensive care unit staff and Change and Networking members. CONCLUSION: This study has described the benefits of using participatory action research to facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. Participatory action research methodology enabled the inclusion of staff to find solutions to design and clinical practice questions. Future research is required to assess the long-term effect of neonatal intensive care unit design on staff workload, maintaining and supporting a skilled workforce as well as the impact of a new neonatal intensive care unit design on the neonatal intensive care unit culture. RELEVANCE TO CLINICAL PRACTICE: A supportive work environment for staff is critical in providing high-quality health care.

Experiences of nurse practitioners and medical practitioners working in collaborative practice models in primary healthcare in Australia - a multiple case study using mixed methods.

BACKGROUND: In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models. METHODS: A multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics. RESULTS: Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners' and medical practitioners' adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals. CONCLUSIONS: Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare.

Educating for health service reform: clinical learning, governance and capability - a case study protocol.

BACKGROUND: The nurse practitioner is a growing clinical role in Australia and internationally, with an expanded scope of practice including prescribing, referring and diagnosing. However, key gaps exist in nurse practitioner education regarding governance of specialty clinical learning and teaching. Specifically, there is no internationally accepted framework against which to measure the quality of clinical learning and teaching for advanced specialty practice. METHODS: A case study design will be used to investigate educational governance and capability theory in nurse practitioner education. Nurse practitioner students, their clinical mentors and university academic staff, from an Australian university that offers an accredited nurse practitioner Master's degree, will be invited to participate in the study. Semi-structured interviews will be conducted with students and their respective clinical mentors and university academic staff to investigate learning objectives related to educational governance and attributes of capability learning. Limited demographic data on age, gender, specialty, education level and nature of the clinical healthcare learning site will also be collected. Episodes of nurse practitioner student specialty clinical learning will be observed and documentation from the students' healthcare learning sites will be collected. Descriptive statistics will be used to report age groups, areas of specialty and types of facilities where clinical learning and teaching is observed. Qualitative data from interviews, observations and student documents will be coded, aggregated and explored to inform a framework of educational governance, to confirm the existing capability framework and describe any additional characteristics of capability and capability learning. DISCUSSION: This research has widespread significance and will contribute to ongoing development of the Australian health workforce. Stakeholders from industry and academic bodies will be involved in shaping the framework that guides the quality and governance of clinical learning and teaching in specialty nurse practitioner practice. Through developing standards for advanced clinical learning and teaching, and furthering understanding of capability theory for advanced healthcare practitioners, this research will contribute to evidence-based models of advanced specialty postgraduate education.

How has the profile of Australian nurse practitioners changed over time?

AIM: To examine longitudinal changes in the profile of Australian nurse practitioners surveyed in both 2007 and 2009 ('resurveyed respondents') and to determine differences between nurse practitioners who completed the census only in 2009 ('new respondents') and resurveyed respondents. BACKGROUND: The nurse practitioner role is integral to the development and sustainability of advanced practice roles in healthcare systems. However, its success depends upon support from policy makers, health services and nursing. A census of Australian nurse practitioners previously was conducted in 2007 to obtain national data on the role and scope of practice of nurse practitioners in Australia. DESIGN: A quantitative self-administered survey. METHODS: Questionnaires were sent to all authorised Australian nurse practitioners in 2009. RESULTS/FINDINGS: A total of 408 surveys were administered with 293 questionnaires completed (response rate 76.3%). Of these, 49% of participants also had completed the 2007 survey. There were no differences in the limitations and enablers identified in 2007 compared to 2009, indicating that perceived barriers had not been addressed over time, nor had there been substantial improvements. New respondents were more likely to have worked as a nurse practitioner in the previous week (p < 0.004). There was a significant increase in the number of nurse practitioners waiting on approval for some or all clinical protocols (p = 0.024). CONCLUSIONS: Conditions enabling work to full scope of practice continue to be perceived as suboptimal by Australian nurse practitioners. Supportive strategies are needed to enable the role to be effectively utilised.

Ciprofloxacin resistance in community- and hospital-acquired Escherichia coli urinary tract infections: a systematic review and meta-analysis of observational studies.

BACKGROUND: During the last decade the resistance rate of urinary Escherichia coli (E. coli) to fluoroquinolones such as ciprofloxacin has increased. Systematic reviews of studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli urinary tract infections (UTI) are absent. This study systematically reviewed the literature and where appropriate, meta-analysed studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli UTIs. METHODS: Observational studies published between 2004 and 2014 were identified through Medline, PubMed, Embase, Cochrane, Scopus and Cinahl searches. Overall and sub-group pooled estimates of ciprofloxacin resistance were evaluated using DerSimonian-Laird random-effects models. The I(2) statistic was calculated to demonstrate the degree of heterogeneity. Risk of bias among included studies was also investigated. RESULTS: Of the identified 1134 papers, 53 were eligible for inclusion, providing 54 studies for analysis with one paper presenting both community and hospital studies. Compared to the community setting, resistance to ciprofloxacin was significantly higher in the hospital setting (pooled resistance 0.38, 95% CI 0.36-0.41 versus 0.27, 95% CI 0.24-0.31 in community-acquired UTIs, P < 0.001). Resistance significantly varied by region and country with the highest resistance observed in developing countries. Similarly, a significant rise in resistance over time was seen in studies reporting on community-acquired E. coli UTI. CONCLUSIONS: Ciprofloxacin resistance in E. coli UTI is increasing and the use of this antimicrobial agent as empirical therapy for UTI should be reconsidered. Policy restrictions on ciprofloxacin use should be enhanced especially in developing countries without current regulations.

Geographical comparisons of information and support needs of Australian women following the primary treatment of breast cancer: a 10-year replication study.

BACKGROUND: In 2002, Raupach and Hiller examined the use of and satisfaction with information and support following treatment of breast cancer from a sample of participants in South Australia. In 2013 this study was replicated to include participants Australia wide and analyse comparisons based on geographical location. Statistical comparisons with the original study were also conducted. DESIGN: A 10 year replication study using a cross-sectional needs analysis survey. SETTING AND PARTICIPANTS: Women aged 18+ years diagnosed with breast cancer between 6 and 30 months ago were sourced from two national databases of women diagnosed with breast cancer. RESULTS: A total of 325 participants completed the survey. The Internet was the most commonly used source of information with 70% (n = 229 of 325) of women using the internet for information, a statistically significantly higher percentage compared with the 2002 study. The study found the top four information issues rated as moderately/extremely important by women in 2013 were identical in 2002. A comparison of sources of support used showed that women in outer regional, remote and very remote areas were statistically more likely to use the breast care nurse (BCN) for support (P = 0.044). CONCLUSIONS: The study provides useful, up-to-date data about information and support services used by Australian women with breast cancer. Comparisons with the earlier study show some of the needs of women have changed over time, but others have remained the same. Geographic comparisons overall, demonstrate many consistent findings regardless of location, however, the important work of the breast care nurse is an area in need of further research.

Literature review: An exploration of the role of the Australian breast care nurse in the provision of information and supportive care.

Breast care nurses (BCNs) were introduced to the Australian health care system in the 1990s to facilitate better continuity of care and increase psychosocial support to women with breast cancer. Yet women with breast cancer, particularly those in rural and remote Australia have high levels of unmet supportive needs. The purpose of this literature review was to examine the role of the Australian breast care nurse in the provision of information and support to women with breast cancer. A literature review was conducted using a number of databases from January 2006 to November 2012. Pre-set criteria were used, and nine research papers were identified; one randomised control trial, five quantitative studies, two qualitative studies and one mixed method study. Of the nine studies identified, only one attempted to explore the national perspective, however participants from Tasmania were not used. Overall, the review revealed very few published Australian studies evaluating the role of the BCN since 2006. The results demonstrate a need for larger studies conducted on a national scale, using participants from diverse geographical areas to gain more insight into the level of access to BCN care experienced by Australian women from both urban and rural and remote areas. It is recommended that further research be undertaken in order to build up a body of quantitative data about the role of the Australian BCN in providing information and support to women.

Addressing the need for an infection prevention and control framework that incorporates the role of surveillance: a discussion paper.

AIM: To present a discussion on theoretical frameworks in infection prevention and control. BACKGROUND: Infection prevention and control programmes have been in place for several years in response to the incidence of healthcare-associated infections and their associated morbidity and mortality. Theoretical frameworks play an important role in formalizing the understanding of infection prevention activities. DESIGN: Discussion paper. DATA SOURCES: A literature search using electronic databases was conducted for published articles in English addressing theoretical frameworks in infection prevention and control between 1980-2012. RESULTS: Nineteen papers that included a reference to frameworks were identified in the review. A narrative analysis of these papers was completed. Two models were identified and neither included the role of surveillance. DISCUSSION: To reduce the risk of acquiring a healthcare-associated infection, a multifaceted approach to infection prevention is required. One key component in this approach is surveillance. The review identified two infection prevention and control frameworks, yet these are rarely applied in infection prevention and control programmes. Only one framework considered the multifaceted approach required for infection prevention. It did not, however, incorporate the role of surveillance. We present a framework that incorporates the role of surveillance into a biopsychosocial approach to infection prevention and control. CONCLUSION: Infection prevention and control programmes and associated research are led primarily by nurses. There is a need for an explicit infection prevention and control framework incorporating the important role that surveillance has in infection prevention activities. This study presents one framework for further critique and discussion.

Investigating characteristics of collaboration between nurse practitioners and medical practitioners in primary healthcare: a mixed methods multiple case study protocol.

AIM: To investigate characteristics of collaboration between nurse practitioners and medical practitioners in the primary healthcare setting in Australia. BACKGROUND: Recent definitions of collaboration in the literature describe it as being based on communication, shared decision-making and the respect and equality of team members. However, research demonstrates a tension between this theoretical ideal and how collaboration between nurse practitioners and medical practitioners occurs in practice. Different socialization processes of the two professions and legislative requirements influence collaborative practice. The way these two professions overcome traditional boundaries and realize collaborative practice in the primary healthcare setting needs to be examined. DESIGN: Mixed methods multiple case study including up to six sites with a minimum of six and a maximum of 20 participants in total. METHODS: Data on collaborative practice between nurse practitioners and medical practitioners in primary health care will be collected in three phases: (1) two-week direct observation in the practice setting to capture actual behaviour and context; (2) questionnaire to measure dimensions of collaboration; and (3) one-to-one semi-structured interviews with nurse practitioners, medical practitioners and practice managers to record experiences, perceptions and understanding of collaboration. DISCUSSION: Triangulation of findings will generate a comprehensive understanding of how collaboration between nurse practitioners and medical practitioners in Australia occurs in the primary care setting. The results of this study will inform nurse practitioners, medical practitioners practice managers and policy makers on successful models of collaboration.

The Fitzpatrick skin type scale: a reliability and validity study in women undergoing radiation therapy for breast cancer.

OBJECTIVE: This study aimed to evaluate the internal consistency reliability and construct validity of the Fitzpatrick Skin Type Scale during radiation therapy in a cohort of women receiving treatment for breast cancer. METHOD: The assessment of the scale was performed as a nested study within a randomised controlled trial of two creams used for radiation therapy skin care for breast cancer patients. The sample consisted of 244 female patients undergoing radiation therapy for breast cancer. Participants completed a modified version of the Fitzpatrick Skin Type Scale. RESULTS: Internal consistency as measured by Cronbach's alpha was 0.505, 0.829 and 0.339 for the Genetic Disposition, Sun Exposure and Tanning Habits subscales respectively. Only the Sun Exposure subscale surpassed the 0.70 cut-off, indicating good internal consistency. Maximum likelihood factor analysis with promax rotation method confirmed the a priori factor structure for the Sun Exposure subscale as well as providing evidence of construct validity for this subscale. Analysis for the other two subscales highlighted issues with internal reliability and construct validity suggesting that not all items on each subscale truly measure the intended trait. CONCLUSION: The study findings support reliability and validity of the Sun Exposure subscale of the Fitzpatrick Skin Type Scale in a convenience sample of women receiving radiation therapy for cancer. Despite limitations with two of the three subscales, this tool continues to be used in clinical practice.

Using the Donabedian framework to examine the quality and safety of nursing service innovation.

AIMS AND OBJECTIVES: To evaluate the safety and quality of nurse practitioner service using the audit framework of Structure, Process and Outcome. BACKGROUND: Health service and workforce reform are on the agenda of governments and other service providers seeking to contain healthcare costs whilst providing safe and effective health care to communities. The nurse practitioner service is one health workforce innovation that has been adopted globally to improve timely access to clinical care, but there is scant literature reporting evaluation of the quality of this service innovation. DESIGN: A mixed-methods design within the Donabedian evaluation framework was used. METHODS: The Donabedian framework was used to evaluate the Structure, Process and Outcome of nurse practitioner service. A range of data collection approaches was used, including stakeholder survey (n = 36), in-depth interviews (11 patients and 13 nurse practitioners) and health records data on service processes. RESULTS: The study identified that adequate and detailed preparation of Structure and Process is essential for the successful implementation of a service innovation. The multidisciplinary team was accepting of the addition of nurse practitioner service, and nurse practitioner clinical care was shown to be effective, satisfactory and safe from the perspective of the clinician stakeholders and patients. CONCLUSIONS: This study demonstrated that the Donabedian framework of Structure, Process and Outcome evaluation is a valuable and validated approach to examine the safety and quality of a service innovation. Furthermore, in this study, specific Structure elements were shown to influence the quality of service processes further validating the framework and the interdependence of the Structure, Process and Outcome components. RELEVANCE TO CLINICAL PRACTICE: Understanding the Structure and Process requirements for establishing nursing service innovation lays the foundation for safe, effective and patient-centred clinical care.