Impact of mentoring relationships on nursing professional socialization.

AIM: This study qualitatively explored the impact mentoring relationships had on the professional socialization of novice clinical nurse leader. BACKGROUND: Professional socialization entails acquisition of the skills, knowledge and values associated with nursing. Model C clinical nurse leaders have completed a bachelor's degree before graduate-level nursing programme acceptance. Thereby, the mentoring needs of model C clinical nurse leaders may differ from that of traditionally educated novice nurses. METHOD: Focus groups were conducted with seven novice model C clinical nurse leaders during their first year of employment. Qualitative data were analysed via a grounded theory approach. RESULTS: The participants described an intense focus on patient care and how multiple mentoring relationships motivated them to become competent bedside clinicians. They described how the mentors' actions enabled them to deal with negative feelings, which increased their confidence, comfort and competence with clinical skills. CONCLUSIONS: Clinical skills improved when a novice model C clinical nurse leader worked with multiple mentors. The qualitative data did not show that the model C clinical nurse leaders needed different mentoring relationships than traditionally educated nurses. IMPLICATION FOR NURSING MANAGEMENT: The results suggest multiple mentors should be used to develop the clinical competences of novice model C clinical nurse leaders.

Effect of mentoring on professional values in model C clinical nurse leader graduates.

BACKGROUND: Nursing graduates acquire their nursing values by professional socialization. Mentoring is a crucial support mechanism for these novice nurses, yet little is known about the model C clinical nurse leader graduate and the effects of mentoring. AIM: This investigation examined how mentoring affected the development of professional nursing values in the model C clinical nurse leader graduate. METHODS: A longitudinal design was used to survey model C clinical nurse leader graduates before and after graduation to determine how different types of mentoring relationships influenced professional values. Demographic surveys documented participant characteristics and the Nurses Professional Values Scale - Revised (NPVS-R) assessed professional nursing values. RESULTS: Mean NPVS-R scores increased after graduation for the formally mentored participants, while the NPVS-R scores decreased or remained unchanged for the other mentoring groups. However, no significant difference was found in NPVS-R scores over time (p = .092) or an interaction between the NPVS-R scores and type of mentoring relationships (p = .09). CONCLUSION: These results suggest that model C clinical nurse leader graduate participants experiencing formal mentoring may develop professional nursing values more than their colleagues. IMPLICATIONS FOR NURSING MANAGEMENT: Formal mentoring relationships are powerful and should be used to promote professional values for model C clinical nurse leader graduates.

Implementation of a Massive Transfusion Protocol: Evaluation of Its Use and Efficacy.

Massive transfusion protocols (MTPs) allow practitioners to follow a prescribed algorithm for the rapid replacement of blood products during a massive hemorrhage. They function as an established protocol to provide consistent treatment. Once implemented, the MTP must be evaluated to ensure best practice. The purpose of this clinical improvement project was to formally evaluate the use and efficacy of an MTP during its first year of implementation. The specific aims were to (1) determine whether MTP activations were missed; (2) compare outcomes between those patients managed by the MTP and those who were not; and (3) provide recommendations to the institution's stakeholders. A retrospective medical record review was conducted with 101 electronic medical records of adult trauma patients treated over 1 year. Patients were identified to have experienced massive bleeding if their medical record contained 1 of 4 indicators: (1) transfusion of uncrossmatched blood; (2) tranexamic acid administration; (3) transfusion of 4 or more units of packed red blood cells (PRBCs) in 1 hr; and/or (4) transfusion of 10 or more units of PRBCs in 24 hr. While 58 patients experienced massive bleeding, only 16 (28%) were managed using the MTP. Although the non-MTP group received fewer transfused blood products due to higher initial and 24-hr hemoglobin levels, more deaths occurred in this group than in the MTP group. The recommendations were to (1) establish well-defined criteria for MTP activation based on the 4 indicators of massive bleeding and (2) regularly evaluate the use and efficacy of the MTP to ensure positive patient outcomes.

Evaluation Tool for Assessing a Newly Implemented Massive Transfusion Protocol.

Exsanguination requires massive blood product replacement and termination of the bleeding source to prevent hemorrhagic shock and death. Massive transfusion protocols (MTPs) are algorithms that allow the health care team to quickly stabilize the bleeding patient and guide blood product administration. However, no national MTP guidelines or a standardized evaluation tool exist for collecting and reporting MTP-related data. The purpose of this article is to describe an original MTP evaluation tool, how it was used, barriers encountered, and a framework for reporting the MTP evaluation data. The evidence-based Broxton MTP Evaluation Tool was developed to evaluate the use of a newly implemented MTP via a retrospective review of electronic medical records (EMRs). Although the instrument itself worked well, barriers were encountered while reviewing the EMRs for the MTP evaluation. These barriers included no institutional entity was charged with tracking MTP activations, no searchable database was established to collect data concerning the MTP-activated patients, and no standard location in the EMR was designated for documenting the MTP activation. When devising protocols such as an MTP, a priori strategies should be developed for its implementation, documentation, and evaluation. Research is needed to determine best practices for evaluating an MTP to ensure positive patient outcomes with this protocol.

Indirectly probing Ca(2+) handling alterations following myocardial infarction in a murine model using T(1)-mapping manganese-enhanced magnetic resonance imaging.

Prolonged ischemia causes cellular necrosis and myocardial infarction (MI) via intracellular calcium (Ca(2+)) overload. Manganese-enhanced MRI indirectly assesses Ca(2+) influx movement in vivo as manganese (Mn(2+)) is a Ca(2+) analog. To characterize myocardial Mn(2+) efflux properties, T(1)-mapping manganese-enhanced MRI studies were performed on adult male C57Bl/6 mice in which Ca(2+) efflux was altered using pharmacological intervention agents or MI-inducing surgery. Results showed that (1) Mn(2+) efflux rate increased exponentially with increasing Mn(2+) doses; (2) SEA0400 (a sodium-calcium exchanger inhibitor) decreased the rate of Mn(2+) efflux; and (3) dobutamine (a positive inotropic agent) increased the Mn(2+) efflux rate. A novel analysis technique also delineated regional features in the MI mice, which showed an increased Mn(2+) efflux rate in the necrosed and peri-infarcted tissue zones. The T(1)-mapping manganese-enhanced MRI technique characterized alterations in myocardial Mn(2+) efflux rates following both pharmacologic intervention and an acute MI. The Mn(2+) efflux results were consistent with those in ex vivo studies showing an increased Ca(2+) concentration under similar conditions. Thus, T(1)-mapping manganese-enhanced MRI has the potential to indirectly identify and quantify intracellular Ca(2+) handling in the peri-infarcted tissue zones, which may reveal salvageable tissue in the post-MI myocardium.

Monitoring bone marrow-originated mesenchymal stem cell traffic to myocardial infarction sites using magnetic resonance imaging.

How stem cells promote myocardial repair in myocardial infarction (MI) is not well understood. The purpose of this study was to noninvasively monitor and quantify mesenchymal stem cells (MSC) from bone marrow to MI sites using magnetic resonance imaging (MRI). MSC were dual-labeled with an enhanced green fluorescent protein and micrometer-sized iron oxide particles prior to intra-bone marrow transplantation into the tibial medullary space of C57Bl/6 mice. Micrometer-sized iron oxide particles labeling caused signal attenuation in T(2)*-weighted MRI and thus allowed noninvasive cell tracking. Longitudinal MRI demonstrated MSC infiltration into MI sites over time. Fluorescence from both micrometer-sized iron oxide particles and enhanced green fluorescent protein in histology validated the presence of dual-labeled cells at MI sites. This study demonstrated that MSC traffic to MI sites can be noninvasively monitored in MRI by labeling cells with micrometer-sized iron oxide particles. The dual-labeled MSC at MI sites maintained their capability of proliferation and differentiation. The dual-labeling, intra-bone marrow transplantation, and MRI cell tracking provided a unique approach for investigating stem cells' roles in the post-MI healing process. This technique can potentially be applied to monitor possible effects on stem cell mobilization caused by given treatment strategies.

Temporal and noninvasive monitoring of inflammatory-cell infiltration to myocardial infarction sites using micrometer-sized iron oxide particles.

Micrometer-sized iron oxide particles (MPIO) are a more sensitive MRI contrast agent for tracking cell migration compared to ultrasmall iron oxide particles. This study investigated the temporal relationship between inflammation and tissue remodeling due to myocardial infarction (MI) using MPIO-enhanced MRI. C57Bl/6 mice received an intravenous MPIO injection for cell labeling, followed by a surgically induced MI seven days later (n=7). For controls, two groups underwent either sham-operated surgery without inducing an MI post-MPIO injection (n=7) or MI surgery without MPIO injection (n=6). The MRIs performed post-MI showed significant signal attenuation around the MI site for the mice that received an intravenous MPIO injection for cell labeling, followed by a surgically induced MI seven days later, compared to the two control groups (P<0.01). The findings suggested that the prelabeled inflammatory cells mobilized and infiltrated into the MI site. Furthermore, the linear regression of contrast-to-noise ratio at the MI site and left ventricular ejection function suggested a positive correlation between the labeled inflammatory cell infiltration and cardiac function attenuation during post-MI remodeling (r2=0.98). In conclusion, this study demonstrated an MRI technique for noninvasively and temporally monitoring inflammatory cell migration into the myocardium while potentially providing additional insight concerning the pathologic progression of a myocardial infarction.

Assessing manganese efflux using SEA0400 and cardiac T1-mapping manganese-enhanced MRI in a murine model.

The sodium-calcium exchanger (NCX) is one of the transporters contributing to the control of intracellular calcium (Ca(2+)) concentration by normally mediating net Ca(2+) efflux. However, the reverse mode of the NCX can cause intracellular Ca(2+) concentration overload, which exacerbates the myocardial tissue injury resulting from ischemia. Although the NCX inhibitor SEA0400 has been shown to therapeutically reduce myocardial injury, no in vivo technique exists to monitor intracellular Ca(2+) fluctuations produced by this drug. Cardiac manganese-enhanced MRI (MEMRI) may indirectly assess Ca(2+) efflux by estimating changes in manganese (Mn(2+)) content in vivo, since Mn(2+) has been suggested as a surrogate marker for Ca(2+). This study used the MEMRI technique to examine the temporal features of cardiac Mn(2+) efflux by implementing a T(1)-mapping method and inhibiting the NCX with SEA0400. The change in (1)H(2)O longitudinal relaxation rate, Delta R(1), in the left ventricular free wall, was calculated at different time points following infusion of 190 nmol/g manganese chloride (MnCl(2)) in healthy adult male mice. The results showed 50% MEMRI signal attenuation at 3.4 +/- 0.6 h post-MnCl(2) infusion without drug intervention. Furthermore, treatment with 50 +/- 0.2 mg/kg of SEA0400 significantly reduced the rate of decrease in Delta R(1). At 4.9-5.9 h post-MnCl(2) infusion, the average Delta R(1) values for the two groups treated with SEA0400 were 2.46 +/- 0.29 and 1.72 +/- 0.24 s(-1) for 50 and 20 mg/kg doses, respectively, as compared to the value of 1.27 +/- 0.28 s(-1) for the control group. When this in vivo data were compared to ex vivo absolute manganese content data, the MEMRI T(1)-mapping technique was shown to effectively quantify Mn(2+) efflux rates in the myocardium. Therefore, combining an NCX inhibitor with MEMRI may be a useful technique for assessing Mn(2+) transport mechanisms and rates in vivo, which may reflect changes in Ca(2+) transport.

Integrating Palliative Care into the Chronic Illness Continuum: a Conceptual Model for Minority Populations.

Although the use of palliative care has increased in recent years, chronically ill Americans within a racial/ethnic minority (non-White) population underutilize this supportive and comfort-giving healthcare service. Consequently, chronically ill minority Americans experience increased pain, symptom burden, and inappropriate use of healthcare resources compared to their white counterparts. A literature review was conducted to compile and synthesize the current state of research pertinent to improving the use of palliative care among chronically ill minority Americans. Selection criteria produced 18 relevant publications, which aided in developing a conceptual model that assimilated early, episodic, and late palliative care phases along the chronic illness continuum. The goal of the conceptual model was to provide a roadmap for healthcare professionals to use when designing, implementing, managing, and/or evaluating palliative care services for chronically ill minority Americans. The literature review demonstrated that minority patients benefitted the most from culturally tailored, systematic interventions (such as advanced care planning education) in all phases of palliative care, which led to increases in advance directive completion, better symptom control, and hospice utilization. The article concludes with a discussion and fictional case study portraying the importance of culturally tailored early palliative care as a catalyst for engaging minority patients in palliative care services.

Improving inpatient venous thromboembolism prophylaxis.

OBJECTIVES: The number and types of inpatients given inadequate prophylaxis for venous thromboembolism (VTE) are not known; patients receive less than appropriate prophylaxis with some frequency. METHODS: Initially we evaluated VTE prophylaxis at a community hospital by comparing prophylaxis patterns in adult inpatients for whom some prophylaxis was indicated. Patients were categorized as medical, general surgery, and orthopedic, then categorized as "appropriate," "suboptimal," or "none" in terms of VTE prophylaxis. After initial data collection, we performed an intervention on medical patients using a VTE risk assessment tool; a printed evaluation containing the VTE risk assessment score with related VTE prophylaxis regimens was placed in the patients' charts, after which prophylaxis patterns were compared between preintervention and postintervention medical patients. RESULTS: Initial data collected from 116 medical, 110 general surgery, and 72 orthopedic patients (n = 298) showed that there was a significant association between diagnosis category and level of observed appropriate VTE prophylaxis (P < 0.0001). Fifty-six medical patients (48%) received no prophylaxis, compared to 40 (36%) general surgery patients and 12 (17%) orthopedic patients. In the second phase, 74 medical patients on whom the intervention was performed were compared to 116 preintervention medical patients (n = 190). The findings showed that intervention status had a significant association with level of appropriate VTE prophylaxis (P < 0.0001). CONCLUSION: An increase in appropriate VTE prophylaxis was observed after a system-level intervention.

Detection of cardiac variability in the isolated rat heart.

Cardiac variability can be assessed from two perspectives: beat-to-beat performance and continuous performance during the cardiac cycle. Linear analysis techniques assess cardiac variability by measuring the physical attributes of a signal, whereas nonlinear techniques evaluate signal dynamics. This study sought to determine if recurrence quantification analysis (RQA), a nonlinear technique, could detect pharmacologically induced autonomic changes in the continuous left ventricular pressure (LVP) and electrographic (EC) signals from an isolated rat heart-a model that theoretically contains no inherent variability. LVP and EC signal data were acquired simultaneously during Langendorff perfusion of isolated rat hearts before and after the addition of acetylcholine (n = 11), norepinephrine (n = 12), or no drug (n = 12). Two-minute segments of the continuous LVP and EC signal data were analyzed by RQA. Findings showed that%recurrence,%determinism, entropy, maxline, and trend from the continuous LVP signal significantly increased in the presence of both acetylcholine and norepinephrine, although systolic LVP significantly increased only with norepinephrine. In the continuous EC signal, the RQA trend variable significantly increased in the presence of norepinephrine. These results suggest that when either the sympathetic or parasympathetic division of the autonomic nervous system overwhelms the other, the dynamics underlying cardiac variability become stationary. This study also shows that information concerning inherent variability in the isolated rat heart can be gained via RQA of the continuous cardiac signal. Although speculative, RQA may be a tool for detecting alterations in cardiac variability and evaluating signal dynamics as a nonlinear indicator of cardiac pathology.

Nonlinear organization of electrocardiogram and optical signals during ventricular fibrillation.

BACKGROUND: Although sympathetic activation may induce ventricular fibrillation (VF), little is known about how the autonomic nervous system influences its nonlinear organization. This study tested the hypothesis that autonomic receptor activation altered the nonlinear organization of VF. METHODS: Isolated rabbit hearts underwent retrograde perfusion with acetylcholine or norepinephrine added to the perfusate. Voltage-sensitive fluorescent images of the ventricular surface were obtained during sustained VF. Concurrent electrocardiogram and optical pixel signals underwent recurrence quantification analysis, which detects and quantifies patterns of repeating data sequences. Recurrence quantification analysis variables signify different aspects of nonlinearity. RESULTS: Recurrence quantification analysis results showed that the electrocardiogram and pixel signals did not exhibit the same pattern of nonlinear organization during VF. Recurrence quantification analysis values were not dramatically altered from baseline by acetylcholine and norepinephrine but instead exhibited considerable variation. CONCLUSION: An alteration in autonomic milieu diminished the nonlinear organization of VF, that is, autonomic receptor activation made VF less likely to behave in a repetitive pattern over time.

Linear and nonlinear approaches to the analysis of R-R interval variability.

Analysis techniques derived from linear and non-linear dynamics systems theory qualify and quantify physiological signal variability. Both clinicians and researchers use physiological signals in their scopes of practice. The clinician monitors patients with signal-analysis technology, and the researcher analyzes physiological data with signal-analysis techniques. Understanding the theoretical basis for analyzing physiological signals within one's scope of practice ensures proper interpretation of the relationship between physiolgical function and signal variability. This article explains the concepts of linear and nonlinear signal analysis and illustrates these concepts with descriptions of power spectrum analysis and recurrence quantification analysis. This article also briefly describes the relevance of these 2 techniques to R-to-R wave interval (i.e., heart rate variability) signal analysis and demonstrates their application to R-to-R wave interval data obtained from an isolated rat heart model.