Job satisfaction as a mediator between structural empowerment and intent-to-leave: A study of critical care nurses.

BACKGROUND: Nurse turnover is an issue that impacts a hospital's financial resources and the quality of patient care. There is a need to discover what actions can be taken to improve nurse retention. OBJECTIVE: Nurses' job satisfaction has been shown to improve organizational outcomes, such as nurses' retention. The objective of this study is to examines the relationship between intent to leave, job satisfaction and structural empowerment (SE), providing a theoretical basis for further research. METHODS: A convenience sample of 83 critical care nurses, recruited from two Facebook groups and the AACN website. The nurses completed a survey that used three tools; Conditions of Work Effectiveness II (CWEQ II), Job Satisfaction Survey (JSS), and Turnover Intention (TIS-6) to address 4 hypotheses to determine the relationship of the three constructs. RESULTS: Findings indicated that SE was not significantly related to intent-to-leave; SE was positively related to job satisfaction (ß=0.760, p<0.01) , and job satisfaction was negatively related to Intent-to-leave (ß=-0.610, p<0.01). CONCLUSION: The research provided a theoretical framework for further research on SE and its importance in improving job satisfaction and reducing turnover in critical nurse.

Geriatric Assessment-Driven Intervention (GAIN) on Chemotherapy-Related Toxic Effects in Older Adults With Cancer: A Randomized Clinical Trial.

IMPORTANCE: Although geriatric assessment-driven intervention improves patient-centered outcomes, its influence on chemotherapy-related toxic effects remains unknown. OBJECTIVE: To assess whether specific geriatric assessment-driven intervention (GAIN) can reduce chemotherapy-related toxic effects in older adults with cancer. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial enrolled 613 participants from a National Cancer Institute-designated cancer center between 2015 and 2019. Patients were 65 years and older with a solid malignant neoplasm, were starting a new chemotherapy regimen, and completed a geriatric assessment. Patients were followed up until chemotherapy completion or 6 months after initiation, whichever occurred first. Data analysis was done by intention-to-treat principle. INTERVENTIONS: Patients were randomized (2:1) to either the GAIN (intervention) or standard of care (SOC) arm. In the GAIN arm, a geriatrics-trained multidisciplinary team composed of an oncologist, nurse practitioner, social worker, physical/occupation therapist, nutritionist, and pharmacist reviewed geriatric assessment results and implemented interventions based on prespecified thresholds built into the geriatric assessment's domains. In the SOC arm, geriatric assessment results were sent to treating oncologists for consideration. MAIN OUTCOMES AND MEASURES: The primary outcome was incidence of grade 3 or higher chemotherapy-related toxic effects (graded using National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0). Secondary outcomes included advance directive completion, emergency department visits, unplanned hospitalizations, average length of stay, unplanned hospital readmissions, chemotherapy dose modifications, and early discontinuation. Overall survival analysis was performed up to 12 months after chemotherapy initiation. RESULTS: Among the 605 eligible participants for analysis, median (range) age was 71 (65-91) years, 357 (59.0%) were women, and 432 (71.4%) had stage IV disease. Cancer types included gastrointestinal (202 [33.4%]), breast (136 [22.5%]), lung (97 [16.0%]), genitourinary (91 [15.0%]), gynecologic (54 [8.9%]), and other (25 [4.1%]). Incidence of grade 3 or higher chemotherapy-related toxic effects was 50.5% (95% CI, 45.6% to 55.4%) in the GAIN arm and 60.6% (95% CI, 53.9% to 67.3%) in the SOC arm, resulting in a significant 10.1% reduction (95% CI, -1.5 to -18.2%; P = .02). A significant absolute increase in advance directive completion of 28.4% with GAIN vs 13.3% with SOC (P < .001) was observed. No significant differences were observed in emergency department visits, unplanned hospitalizations, average length of stay, unplanned readmissions, chemotherapy dose modifications or discontinuations, or overall survival. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, integration of multidisciplinary GAIN significantly reduced grade 3 or higher chemotherapy-related toxic effects in older adults with cancer. Implementation of GAIN into oncology clinical practice should be considered among older adults receiving chemotherapy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02517034.

Effects of danicamtiv, a novel cardiac myosin activator, in heart failure with reduced ejection fraction: experimental data and clinical results from a phase 2a trial.

AIMS: Both left ventricular (LV) and left atrial (LA) dysfunction and remodelling contribute to adverse outcomes in heart failure with reduced ejection fraction (HFrEF). Danicamtiv is a novel, cardiac myosin activator that enhances cardiomyocyte contraction. METHODS AND RESULTS: We studied the effects of danicamtiv on LV and LA function in non-clinical studies (ex vivo: skinned muscle fibres and myofibrils; in vivo: dogs with heart failure) and in a randomized, double-blind, single- and multiple-dose phase 2a trial in patients with stable HFrEF (placebo, n = 10; danicamtiv, n = 30; 50-100 mg twice daily for 7 days). Danicamtiv increased ATPase activity and calcium sensitivity in LV and LA myofibrils/muscle fibres. In dogs with heart failure, danicamtiv improved LV stroke volume (+10.6 mL, P < 0.05) and LA emptying fraction (+10.7%, P < 0.05). In patients with HFrEF (mean age 60 years, 25% women, ischaemic heart disease 48%, mean LV ejection fraction 32%), treatment-emergent adverse events, mostly mild, were reported in 17 patients (57%) receiving danicamtiv and 4 patients (40%) receiving placebo. Danicamtiv (at plasma concentrations ≥2000 ng/mL) increased stroke volume (up to +7.8 mL, P < 0.01), improved global longitudinal (up to -1.0%, P < 0.05) and circumferential strain (up to -3.3%, P < 0.01), decreased LA minimal volume index (up to -2.4 mL/m2 , P < 0.01) and increased LA function index (up to 6.1, P < 0.01), when compared with placebo. CONCLUSIONS: Danicamtiv was well tolerated and improved LV systolic function in patients with HFrEF. A marked improvement in LA volume and function was also observed in patients with HFrEF, consistent with pre-clinical findings of direct activation of LA contractility.

Selective versus routine patch metal allergy testing to select bar material for the Nuss procedure in 932 patients over 10years.

AIM OF THE STUDY: The aim of the study was to determine the role of patch metal allergy testing to select bar material for the Nuss procedure. METHODS: An IRB-approved (11-04-WC-0098) single institution retrospective, cohort study comparing selective versus routine patch metal allergy testing to select stainless steel or titanium bars for Nuss repair was performed. In Cohort A (9/2004-1/2011), selective patch testing was performed based on clinical risk factors. In Cohort B (2/2011-9/2014), all patients were patch tested. The cohorts were compared for incidence of bar allergy and resultant premature bar loss. Risk factors for stainless steel allergy or positive patch test were evaluated. MAIN RESULTS: Cohort A had 628 patients with 63 (10.0%) selected for patch testing, while all 304 patients in Cohort B were tested. Over 10years, 15 (1.8%) of the 842 stainless steel Nuss repairs resulted in a bar allergy, and 5 had a negative preoperative patch test. The incidence of stainless steel bar allergy (1.8% vs 1.7%, p=0.57) and resultant bar loss (0.5% vs 1.3%, p=0.23) was not statistically different between cohorts. An allergic reaction to a stainless steel bar or a positive patch test was more common in females (OR=2.3, p<0.001) and patients with a personal (OR=24.8, p<0.001) or family history (OR=3.1, p<0.001) of metal sensitivity. CONCLUSION: Stainless steel bar allergies occur at a low incidence with either routine or selective patch metal allergy testing. If selective testing is performed, it is advisable in females and patients with a personal or family history of metal sensitivity. A negative preoperative patch metal allergy test does not preclude the possibility of a postoperative stainless steel bar allergy. LEVEL OF EVIDENCE: Level III Treatment Study and Study of Diagnostic Test.

Commitment to health theory: a graphic model.

Graphic models can improve understanding of theoretical concepts and the relationship between concepts. This article introduces a model of Commitment to Health Theory, which describes the process of behavior change from action to the maintenance stage of change. Commitment to health means that a new or modified health behavior will be used regardless of socioeconomic factors, race, gender, employment category, and age. Findings were based on three cross-sectional survey studies of approximately 1,085 predominantly manufacturing workers sampled from across the United States. Commitment to Health Theory was used to identify those in the action stage of change with mid-level commitment and predict the likelihood of successfully changing health behavior. Monitoring levels of commitment to health can determine appropriate intervention strategies to assist clients who currently exhibit unhealthy diet and exercise behaviors.

High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing.

PURPOSE: A previous study from our group estimated that as few as 2.2% of pectus excavatum patients suffered from allergy to the implanted metal bar. We sought to assess recent changes in incidence of metal allergy and identify the benefit of metal allergy testing prior to surgery. METHODS: A retrospective review was performed of all consenting patients undergoing pectus repair during the six years between 9/2004 and 12/2010 at our institution. Incidence was based on clinical symptoms and/or T.R.U.E.® patch testing. Demographic data, history of atopy and history of metal allergy were collected. Type and number of bars used, suture site infection, skin rash and wound infection rates were reviewed. RESULTS: Forty one of 639 patients (6.4%) had clinical or patch test evidence of metal allergy. Family history of metal allergy and pre-operative history of metal sensitivity were found to be statistically significant correlates. CONCLUSIONS: The rate of metal allergy in the pectus excavatum population may be higher than previously reported. Patient or family history of metal allergy or metal sensitization may indicate increased risk. Metal allergy testing should be performed before Nuss procedure.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest.

OBJECTIVE: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. METHODS: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. RESULTS: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). CONCLUSION: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Commitment to health: a predictor of dietary change.

AIMS AND OBJECTIVES: To determine the predictive validity of three behavioural variables on changes in diet: commitment to health (commitment), confidence in ability to change dietary behaviours (confidence) and belief about the importance of changing dietary behaviours (importance). BACKGROUND: Literature supports the Transtheoretical Model of Behavior Change as a framework for understanding dietary behaviour change. Less certain are behavioural variables associated with stage movement for action to maintenance stage for dietary behaviour change. This research considered three variables: self-efficacy ('confidence'), decisional balance scale ('importance') and 'commitment'. Published literature supports the importance of each of these behavioural variables, but not their predictive abilities. DESIGN: A cross-sectional survey was used for 499 manufacturing workers from multiple work-sites. METHODS: Subjects' dietary health behaviours were measured by determining how long they consistently ate a low-fat diet, with analysis of variance addressing the stages-of-change model: precontemplation, contemplation, preparation, action, maintenance. RESULTS: Commitment best predicted change from action to maintenance stage (p < 0·05). Importance (p < 0·05) was somewhat significant, but confidence (p > 0·05) was not. CONCLUSIONS: Commitment was the best predictor of dietary change, from the action to the maintenance stage of change. RELEVANCE TO CLINICAL PRACTICE: Clinicians working with patients in the action stage of dietary change can use a stage-based approach and should evaluate commitment to health as part of an overall assessment. Those with high-level commitment will successfully change from action to maintenance with minimal professional assistance. Those with middle-level commitment risk relapse to a pre-action stage will benefit most from professional intervention. Those in the lower level of commitment are most likely to revert to a pre-action stage of change and may be not be ready for dietary change.

Second degree prelicensure master's graduates: what attracts them to nursing, their views on the profession, and their contributions.

This qualitative study explored second degree prelicensure master's graduates' attraction to the nursing profession, views on nursing, and thoughts regarding their contribution to nursing. Fourteen individuals participated from a cohort of master's students enrolled in a second degree program with a Clinical Nurse Leader focus. Data were collected through researcher-participant interviews. The researchers categorized data according to interview questions using constant comparison. Within each category, central themes emerged. Findings revealed that participants were drawn to nursing because of the opportunities and the caring nature of nursing. Participants felt prepared and excited to start a second career despite having to overcome challenges. They believed that their previous education enhanced their communication abilities and broadened their views; however, they encountered difficulties integrating previously held perspectives into a nursing worldview. They found poor nurse-to-nurse relationships among some experienced nurses and the difficulty of nursing education surprising. The opportunity to help others and the people for whom they provided care were the two features the participants most liked about nursing. Understanding such insights is important to continue to attract individuals from other careers to nursing. Findings highlight the important contributions that these individuals bring to the profession.

Second-degree prelicensure master's graduates and their transition to practice.

OBJECTIVE: The purpose of this study was to gain an understanding of the transition-to-practice experience of second-degree prelicensure master's graduates. BACKGROUND: Second-degree graduates are increasingly joining the nursing workforce. Scant empirical literature exists regarding this group. METHODS: Using a qualitative design, second-degree prelicensure master's graduates were interviewed 3 times through a 10-month period regarding their transition to practice. RESULTS: Participants chose nursing positions based on their perceived ability to grow. Two strengths of the participants included their ability to think critically and to establish relationships. Participants expressed typical novice nurse concerns. Residency and intern programs enhanced their transition to practice. Participants perceived their interactions with the health team as positive, and graduates urged administrators to use their knowledge gained from previous degrees. CONCLUSIONS: Findings enhance understanding of how second-degree prelicensure master's graduates transition to practice. Understanding their transition is imperative if these graduates are to be recruited and used at their fullest potential. Such insights can also help nurse administrators better support these new hires during the transition process.

Therapeutic enhancement: nursing intervention category for patients diagnosed with Readiness for Therapeutic Regimen Management.

AIMS: To present a new nursing intervention category called therapeutic enhancement. BACKGROUND: Fewer than half of North Americans follow their physician's recommendations for diet and exercise, even when such are crucial to their health or recovery. It is imperative that nurses consider new ways to promote healthy behaviours. Therapeutic enhancement is intended to provide such a fresh approach. Traditional intervention techniques focusing on education, contracts, social support and more frequent interaction with physicians appear not to be effective when used alone. Successful strategies have been multidisciplinary; and have included interventions by professional nurses who assist patients to understand their disease and the disease process and that helps them to develop disease-management and self-management skills. Therapeutic enhancement incorporates The Stages of Change Theory, Commitment to Health Theory, Motivational Interviewing techniques and instrumentation specifically designed for process evaluation of health-promoting interventions. METHOD: This is a critical review of approaches that, heretofore, have not been synthesised in a single published article. CONCLUSIONS: Based on the commonly used Stages of Change model, therapeutic enhancement is useful for patients who are at the action stage of change. Using therapeutic enhancement as well as therapeutic strategies identified in Stages of Change Theory, such as contingency management, helping relationships, counterconditioning, stimulus control and Motivational Interviewing techniques, nursing professionals can significantly increase the chances of patients moving from action to the maintenance stage of change for a specific health behaviour. RELEVANCE TO CLINICAL PRACTICE: Using the nursing intervention category, therapeutic enhancement can increase caregivers' success in helping patients maintain healthy behaviours.

Commitment to health theory.

This article introduces commitment to health as a middle-range. Commitment to health (CTH) is derived from Prochaska and DiClemente's (1983) Transtheoretical Model of Behavior Change. CTH theory is designed to predict the likelihood of behavior change between the action and maintenance stages of change. Commitment is defined as a freely chosen internal resolve to perform health behaviors, even when encumbered or inconvenienced by difficulties. Health is defined as the optimal level of well-being. Commitment is an independent continuous variable, but it can be categorized into three time-oriented categories: (1) low-level, (2) middle-level, and (3) high-level commitment. The higher the level of commitment, the more likely the individual will adopt long-term behavior change. This article presents the definitions, assumptions, and relational statements of CTH.

Correlation between respiratory colonization with gram-negative bacteria and development of gram-negative bacterial infection after cardiac surgery.

This pilot, observational study involving 286 patients who underwent cardiac surgery found that patients who had endotracheal colonization with gram-negative bacteria at 1 week after surgery were more likely to develop subsequent infection compared to those without colonization (8 of 23 vs. 4 of 40; relative risk 2.3 [95% confidence interval, 1.3-4.1; P value <.05]).

Intraarterial chemotherapy for extremity osteosarcoma and MFH in adults.

UNLABELLED: The neoadjuvant treatment of osteosarcoma using intravenous agents has resulted in survival rates of 55% to 77% [3, 5, 6, 20, 22, 35]. We designed a neoadjuvant chemotherapy protocol using combined intraarterial and intravenous agents to treat high-grade osteosarcoma and malignant fibrous histiocytoma of bone in an attempt to improve survival. We report the results of treating 53 adults (age 18-77 years) diagnosed with nonmetastatic extremity osteosarcoma or malignant fibrous histiocytoma. Preoperative chemotherapy consisted of intravenous doxorubicin followed by intraarterial cisplatinum administered repetitively every 3 weeks for three to five cycles, depending on tumor response assessed by serial arteriography. Dose and duration of cisplatin were adjusted for tumor size. After resection, good responders (90% or greater necrosis) underwent treatment with the same agents and poor responders were treated with alternative agents for longer duration. Minimum followup was 24 months (mean, 111 months; range, 24-235 months). Estimated Kaplan-Meier survival at 10 years was 82% and event-free survival was 79%. Forty-one patients (77%) had a good histologic response and 92% (49 of 53) underwent limb-sparing procedures. Local recurrence occurred in two patients (4%). These results compared favorably with those reported in the current literature. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Measuring the distribution of health behaviors in working populations--the needs assessment.

In this study, 79% of employees had one or more unhealthy behaviors that could result in disease or injury. needs assessment can be used to identify individual employees who have unhealthy behaviors and may be ready for behavior change. Focused health behavior interventions for employees who are ready to make a behavior change are more effective than generalized health promotion.

Providing asthma care in elementary schools: understanding barriers to determine best practices.

School nurses play a critical role in the management of children's asthma, yet they face barriers in their efforts to deliver quality care. In this qualitative study involving focus groups with school nurses, we identified key barriers in order to inform best practices. School nurses identified 4 main barriers to effective asthma care in elementary schools: lack of education, lack of communication, lack of resources, and lack of respect. An analysis of the barriers suggests that best practices for asthma care in elementary school settings require collaborative strategies that involve schools, families, the community, and the healthcare profession.