The Healthcare Environment Survey: A multicountry psychometric evaluation of nurses' job satisfaction.

AIM: To evaluate the properties of a reduced-item Healthcare Environment Survey measuring nurses' job satisfaction across eight countries. BACKGROUND: There is currently no rigorously tested international measure of nurses' job satisfaction that can be used internationally to improve the nurse work environment. METHODS: Nursing staff from 11 hospitals in eight countries participated in this study. The original 57-item, 11-facet Healthcare Environment Survey was evaluated for reliability, validity, and measurement invariance: Cronbach's alpha was used to test for reliability; construct, discriminate, and convergent testing were used to test validity; and invariance testing including configural, metric, and scalar tests were used to study measurement invariance between the countries. RESULTS: 2,046 nursing staff completed the survey. Reliability was established for all six subscales and the combined composite score. Both validity and measurement invariance were supported in every test conducted. An excellent model fit was found for the final 19-item, 6-facet Healthcare Environment Survey that explained 82% of the variance of nurses' job satisfaction. CONCLUSIONS: Findings suggest the instrument is an efficient measure of nurses' job satisfaction across multiple countries. Longitudinal testing for invariance will be needed to ensure the model remains a good fit. Testing more countries will also verify model fit. IMPLICATIONS FOR NURSING: The instrument can be used to measure nurse job satisfaction globally. IMPLICATIONS FOR NURSING POLICY: The instrument can be used to assess interventions to improve the social (patient, unit manager, and coworker) and technical (professional rewards, autonomy, and professional growth) aspects of nurse job satisfaction.

Shared Components of the FRQ-Less Oscillator and TOR Pathway Maintain Rhythmicity in Neurospora.

Molecular models for the endogenous oscillators that drive circadian rhythms in eukaryotes center on rhythmic transcription/translation of a small number of "clock genes." Although substantial evidence supports the concept that negative and positive transcription/translation feedback loops (TTFLs) are responsible for regulating the expression of these clock genes, certain rhythms in the filamentous fungus Neurospora crassa continue even when clock genes (frq, wc-1, and wc-2) are not rhythmically expressed. Identification of the rhythmic processes operating outside of the TTFL has been a major unresolved area in circadian biology. Our lab previously identified a mutation (vta) that abolishes FRQ-less rhythmicity of the conidiation rhythm and also affects rhythmicity when FRQ is functional. Further studies identified the vta gene product as a component of the TOR (Target of Rapamycin) nutrient-sensing pathway that is conserved in eukaryotes. We now report the discovery of TOR pathway components including GTR2 (homologous to the yeast protein Gtr2, and RAG C/D in mammals) as binding partners of VTA through co-immunoprecipitation (IP) and mass spectrometry analysis using a VTA-FLAG strain. Reciprocal IP with GTR2-FLAG found VTA as a binding partner. A Δgtr2 strain was deficient in growth responses to amino acids. Free-running conidiation rhythms in a FRQ-less strain were abolished in Δgtr2. Entrainment of a FRQ-less strain to cycles of heat pulses demonstrated that Δgtr2 is defective in entrainment. In all of these assays, Δgtr2 is similar to Δvta. In addition, expression of GTR2 protein was found to be rhythmic across two circadian cycles, and functional VTA was required for GTR2 rhythmicity. FRQ protein exhibited the expected rhythm in the presence of GTR2 but the rhythmic level of FRQ dampened in the absence of GTR2. These results establish association of VTA with GTR2, and their role in maintaining functional circadian rhythms through the TOR pathway.

Advancing the clinical nurse leader model through academic-practice-policy partnership.

The nursing profession is tasked with identifying and evaluating models of care with potential to add value to health care delivery. In consideration of this goal, we describe the Clinical Nurse Leader (CNL) initiative and the activities of a national-level CNL research collaborative. The CNL initiative, launched by the American Association of Colleges of Nursing in collaboration with education and healthcare leaders, has delineated CNL education curriculum and practice competencies, and fostered the creation of academic-practice-policy partnerships to pilot CNL integration into frontline nursing care delivery. The partnership has evolved into an Agency for Healthcare Research and Quality affiliate practice-based research network, the CNL Research Collaborative, which links research, policy, education, and practice stakeholders to advance the CNL evidence base. We summarize foundational CNLRC research to explain CNL practice, quantify CNL effectiveness, and bring clarity to how CNLs can be implemented to consistently influence care, quality, and safety.

Developing the Clinical Nurse Leader Survey Instrument: A Modified Delphi Study.

Clinical nurse leader (CNL)-integrated care delivery is an emerging nursing model, with growing adoption in diverse health systems. To generate a robust evidence base for this promising nursing model, it is necessary to measure CNL practice to explicitly link it to observed quality and safety outcome improvements. This study used a modified Delphi approach with an expert CNL panel to develop and test the face, content, and construct validity of the CNL Practice Survey instrument.

Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals.

BACKGROUND: Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework. METHODS: This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention. Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended). RESULTS: Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated; 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. IMPLEMENTATION: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive ("user friendly," "streamlined," or "saves time"), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended. CONCLUSIONS: Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01309217.

Effectiveness of the Tobacco Tactics Program in the Trinity Health System.

INTRODUCTION: This study determined the effectiveness of the Tobacco Tactics intervention. DESIGN/SETTING/PARTICIPANTS: This was a pragmatic, quasi-experimental study conducted from 2010 to 2013 and analyzed from 2014 to 2015 in five Michigan community hospitals; three received the Tobacco Tactics intervention, and two received usual care. Smokers (N=1,528) were identified during hospitalization, and sent surveys and cotinine tests after 6 months. Changes in pre- to post-intervention quit rates in the intervention sites were compared with usual care control sites. INTERVENTION: The toolkit for nurses included: (1) 1 continuing education unit contact hour for training; (2) a PowerPoint presentation on behavioral and pharmaceutical interventions; (3) a pocket card entitled "Helping Smokers Quit: A Guide for Clinicians"; (4) behavioral and pharmaceutical protocols; and (5) a computerized template for documentation. The toolkit for patients included: (1) a brochure; (2) a cessation DVD; (3) the Tobacco Tactics manual; (4) a 1-800-QUIT-NOW card; (5) nurse behavioral counseling and pharmaceuticals; (6) physician reminders to offer brief advice to quit coupled with medication sign-off; and (7) follow-up phone calls by trained hospital volunteers. MAIN OUTCOME MEASURES: The effectiveness of the intervention was measured by 6-month 30-day point prevalence; self-reported quit rates with NicAlert(®) urinary biochemical verification (48-hour detection period); and the use of electronic medical record data among non-responders. RESULTS: There were significant improvements in pre- to post-intervention self-reported quit rates (5.7% vs 16.5%, p<0.001) and cotinine-verified quit rates (4.3% vs 8.0%, p<0.05) in the intervention sites compared with no change in the control sites. Propensity-adjusted multivariable analyses showed a significant improvement in self-reported 6-month quit rates from the pre- to post-intervention time periods in the intervention sites compared to the control sites (p=0.044) and a non-statistically significant improvement in the cotinine-verified 6-month quit rate. CONCLUSIONS: The Tobacco Tactics intervention, which meets the Joint Commission standards for inpatient smoking, has the potential to significantly decrease smoking among inpatient smokers. TRIAL REGISTRATION: This study is registered at www.clinicaltrial.gov NCT01309217.

Dissemination of the nurse-administered Tobacco Tactics intervention versus usual care in six Trinity community hospitals: study protocol for a comparative effectiveness trial.

BACKGROUND: The objectives of this smoking cessation study among hospitalized smokers are to: 1) determine provider and patient receptivity, barriers, and facilitators to implementing the nurse-administered, inpatient Tobacco Tactics intervention versus usual care using face-to-face feedback and surveys; 2) compare the effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention versus usual care across hospitals, units, and patient characteristics using thirty-day point prevalence abstinence at thirty days and six months (primary outcome) post-recruitment; and 3) determine the cost-effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention relative to usual care including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved. METHODS/DESIGN: This effectiveness study will be a quasi-experimental design of six Michigan community hospitals of which three will get the nurse-administered Tobacco Tactics intervention and three will provide their usual care. In both the intervention and usual care sites, research assistants will collect data from patients on their smoking habits and related variables while in the hospital and at thirty days and six months post-recruitment. The intervention will be integrated into the experimental sites by a research nurse who will train Master Trainers at each intervention site. The Master Trainers, in turn, will teach the intervention to all staff nurses. Research nurses will also conduct formative evaluation with nurses to identify barriers and facilitators to dissemination.Descriptive statistics will be used to summarize the results of surveys administered to nurses, nurses' participation rates, smokers' receipt of specific cessation services, and satisfaction with services. General estimating equation analyses will be used to determine differences between intervention groups on satisfaction and quit rates, respectively, with adjustment for the clustering of patients within hospital units. Regression analyses will test the moderation of the effects of the interventions by patient characteristics. Cost-effectiveness will be assessed by constructing three ratios including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved. DISCUSSION: Given that nurses represent the largest group of front-line providers, this intervention, if proven effective, has the potential for having a wide reach and thus decrease smoking, morbidity and mortality among inpatient smokers. TRIAL REGISTRATION: Dissemination of Tobacco Tactics for Hospitalized Smokers NCT01309217.

Charge nurses as front-line leaders: development through transformative learning.

Based on the results of a staff satisfaction survey, nurse leaders recognized that the role of charge nurse was a significant source of dissatisfaction. Little attention had been paid to how the charge nurse role was learned, and no organizational support was offered to develop nurses for this role. Collaborating with a nurse educator consultant, nurse managers developed and implemented a three-part educational program to reframe staff perceptions of the charge nurse role. Centered on principles of transformational learning, the program evaluation demonstrated that concerted efforts to improve staff satisfaction and effectiveness could be accomplished if staff were given new information and guided through focused discussion and reflection. Eighty-two percent of the attendees noted that they appreciated the time allocated for the sessions and acknowledged that this gave them an opportunity to examine their thoughts and feelings. Seventy-five percent said that they learned new words to describe and explain their experiences. After the sessions, staff described a new sense of professional pride and nurse managers observed greater confidence in nurses' decision making and assertive communication.

The genetics of circadian rhythms in Neurospora.

This chapter describes our current understanding of the genetics of the Neurospora clock and summarizes the important findings in this area in the past decade. Neurospora is the most intensively studied clock system, and the reasons for this are listed. A discussion of the genetic interactions between clock mutants is included, highlighting the utility of dissecting complex mechanisms by genetic means. The molecular details of the Neurospora circadian clock mechanism are described, as well as the mutations that affect the key clock proteins, FRQ, WC-1, and WC-2, with an emphasis on the roles of protein phosphorylation. Studies on additional genes affecting clock properties are described and place these genes into two categories: those that affect the FRQ/WCC oscillator and those that do not. A discussion of temperature compensation and the mutants affecting this property is included. A section is devoted to the observations pertinent to the existence of other oscillators in this organism with respect to their properties, their effects, and their preliminary characterization. The output of the clock and the control of clock-controlled genes are discussed, emphasizing the phasing of these genes and the layers of control. In conclusion, the authors provide an outlook summarizing their suggestions for areas that would be fruitful for further exploration.

Considering a career change to a nursing faculty position? Key interview questions to ask and why.

Nursing is a practice profession that transitions some bedside clinicians to another career, such as a nursing faculty member in a university nursing program. Given the current faculty shortage, many clinicians may be considering this kind of transition. The nurse considering such a career change can benefit from learning about the job expectations of academe and being prepared to ask questions in the initial interview that may impact future satisfaction and retention. Awareness of job expectations in the areas of teaching, scholarship, service, and practice and consideration of key levels of individuals who will participate in the series of interviews provide the background for such questions. The lessons learned presented in this article were written a year after one of the author's initial faculty interviews and reflect on the advantages of preparation.

Case manager role definitions: do they make an organizational impact?

PURPOSE OF STUDY: This study examined 2 case management delivery models related to defined case manager role responsibilities in a large midwest hospital. Of interest was whether organization-wide outcomes related to reduction in length of stay (LOS) could be achieved by altering the case manager's role functions across medical, surgical, and cardiology units in general, intermediate, and intensive levels of care. In addition, there was curiosity about the timing of the admission and whether LOS would be influenced by the experience of the case manager with new role functions. The first model encompassed a traditional case management model where the case manager's primary functions were discharge planning and utilization review. The second model, the full immersion model, decreased the case manager's caseloads and expanded role functions to encompass daily expectations for chart review, electronic documentation, and communication with members of the interdisciplinary team. PRIMARY PRACTICE SETTING: Acute care hospital inpatient medical, surgical, and cardiology care units. METHODS AND SAMPLE: A causal-comparative retrospective study that included 39,017 medical, surgical, and cardiology inpatients who received care on general, intermediate, and intensive care units. Descriptive and inferential statistics were used to analyzed LOS in the traditional and full immersion models across clinical specialty units and levels of care. IMPLICATION FOR CASE MANAGEMENT PRACTICE: Statistically significant reductions in LOS were achieved using the full immersion model of case management across clinical specialties and levels of care. In addition, the timing of the admission during the implementation of the full immersion model was not statistically significant, highlighting that organizational impacts could be expected at the time of implementation of the model and that the experience of the case manager with the roles functions did not have a negative impact on achieving reduction in LOS with the full immersion model.

New models for circadian systems in microorganisms.

Microorganisms provide important model systems for studying circadian rhythms, and they are overturning established ideas about the molecular mechanisms of rhythmicity. The transcription/translation feedback model that has been accepted as the basis of circadian clock mechanisms in eukaryotes does not account for old data from the alga Acetabularia demonstrating that transcription is not required for rhythmicity. Moreover, new results showing in vitro rhythmicity of KaiC protein phosphorylation in the cyanobacterium Synechococcus, and rhythmicity in strains of the fungus Neurospora carrying clock gene null mutations, require new ways of looking at circadian systems.

Transcriptional feedback oscillators: maybe, maybe not...

The molecular mechanism of circadian rhythmicity is usually modeled by a transcription/translation feedback oscillator in which clock proteins negatively feed back on their own transcription to produce rhythmic levels of clock protein mRNAs, which in turn cause the production of rhythmic levels of clock proteins. This mechanism has been applied to all model organisms for which molecular data are available. This review summarizes the increasing number of anomalous observations that do not fit the standard molecular mechanism for the model organisms Acetabularia, Synechococcus, Drosophila, Neurospora, and mouse. The anomalies fall into 2 classes: observations of rhythmicity in the organism when transcription of clock genes is held constant, and rhythmicity in the organism when clock gene function is missing in knockout mutants. It is concluded that the weight of anomalies is now so large that the standard transcription/translation mechanism is no longer an adequate model for circadian oscillators. Rhythmic transcription may have other functions in the circadian system, such as participating in input and output pathways and providing robustness to the oscillations. It may be most useful to think in terms of a circadian system that uses a noncircadian oscillator consisting of metabolic feedback loops, which acquires its circadian properties from additional regulatory molecules such as the products of canonical clock genes.

Circadian clock genes frequency and white collar-1 are not essential for entrainment to temperature cycles in Neurospora crassa.

The fungus Neurospora crassa is a model system for investigating the mechanism of circadian rhythmicity, and the core of its circadian oscillator is thought to be a transcription/translation feedback loop involving the products of the frq (frequency), wc-1 (white-collar-1) and wc-2 (white-collar-2) genes. Several reports of rhythmicity in frq and wc null mutants have raised questions about how central the FRQ/WC loop is to the circadian system of Neurospora. Several research groups have attempted to answer this question by looking for entrainment of the conidiation banding rhythm in frq null mutants. Because the frq mutants are blind to light and cannot be entrained to light/dark cycles, these groups have used symmetric temperature cycles of equal-duration cool and warm phases to entrain the rhythm. Under these conditions, the direct effects of temperature on conidiation (masking effects) can compromise observations of the endogenous rhythm. I have reexamined this question by using short heat pulses to clearly separate masking from endogenous rhythms, and I have assayed entrainment in both frq and wc-1 null mutants. I found similar patterns of entrainment in the wild type and both mutant strains. Strong masking effects were found in the frq mutant but not in the wc-1 mutant. I conclude that a rapidly damping temperature-entrainable oscillator is present in the null mutants. A single temperature-entrainable oscillator may drive the conidiation rhythm in all strains, and additional properties such as light sensitivity and temperature compensation may be conferred by the intact FRQ/WC loop in the WT strain.

Time-lapse analysis of the circadian rhythms of conidiation and growth rate in neurospora.

The filamentous fungus Neurospora crassa has frequently served as a model organism for the study of circadian rhythms through its ability to form conidial spores on a daily basis. This phenomenon leaves a spatial pattern of conidiation bands along a solid surface of agar after several days of growth. Using time-lapse video, the authors have quantified the rate of conidiation. They have found that conidia do not form at a specified lag time after the growth front is laid down, but rather the band region tends to simultaneously develop over a short time frame. This produces a sharp peak when the conidiation rate is plotted against time. In addition, the authors used time-lapse video to assay growth rate with greater accuracy than previously reported. It is usually assumed that Neurospora's rate of growth is constant, and this assumption of linear growth has been used extensively to determine period and phase of the conidiation circadian rhythm. The authors have confirmed an earlier report of nonlinear growth rate and have shown that the growth rate varies by a factor of about 2 with each circadian cycle. They have demonstrated that the errors in calculating times of conidiation peaks are maximally 1 to 2 h if linearity is assumed. The conidiation rate and growth rate rhythms are not apparent under conditions (using mutants or high or low temperatures) where the spatial banding rhythm is not observed. In light/dark entraining conditions, the conidiation rate and growth rate rhythms maintain the same phase relationship in different T-cycles. These data are consistent with the hypothesis that the growth rate rhythm is a consequence of the conidiation rate rhythm.

Circadian rhythms in microorganisms: new complexities.

Recent advances in understanding circadian (daily) rhythms in the genera Neurospora, Gonyaulax, and Synechococcus are reviewed and new complexities in their circadian systems are described. The previous model, consisting of a unidirectional flow of information from input to oscillator to output, has now expanded to include multiple input pathways, multiple oscillators, multiple outputs; and feedback from oscillator to input and output to oscillator. New posttranscriptional features of the frq/white-collar oscillator (FWC) of Neurospora are described, including protein phosphorylation and degradation, dimerization, and complex formation. Experimental evidence is presented for frq-less oscillator(s) (FLO) downstream of the FWC. Mathematical models of the Neurospora system are also discussed.