An international comparison of student nurse practitioner diagnostic reasoning skills.

BACKGROUND: Nurse practitioners (NPs) play a pivotal role in health care provision. Diagnostic reasoning is an important core skill of advanced practice. PURPOSE: The purpose of this study was to compare diagnostic reasoning skills of NP students. It also identified the variability in clinical teaching components of a sample of international NP curricula. METHODS: An international group of NP students completed an online survey using a validated diagnostic reasoning scale during the first year of their NP program. Program faculty surveyed provided data on core curricula. RESULTS: The NP students' ( n = 152) mean diagnostic thinking inventory (DTI) score was 142, flexibility in thinking subscale score mean of 73 with a knowledge structure in memory of 69. The programs surveyed required bioscience courses. Most programs provided opportunities for students to practice diagnostic thinking using individual precepted clinical hours (range 500-950) and objective structured clinical examinations. CONCLUSION: The lower scores of this group of NP students were similar to other NP students and first-year medical residents. Higher mean scores in the DTI reflect expertise and are developed over time. Courses providing a foundation of biomedical knowledge were identified in each program, with opportunities for the NP students to practice diagnostic thinking using objective structured clinical examinations and clinical practice hours. IMPLICATIONS: The use of the diagnostic reasoning inventory is a useful tool for evaluating student NP's diagnostic reasoning during their NP program. Nurse practitioner programs should consider the provision of dedicated clinical hours, including supervised clinical practice experiences and objective structured clinical examinations to improve diagnostic reasoning.

Nuclear Resonance Vibrational Spectroscopy Definition of Peroxy Intermediates in Catechol Dioxygenases: Factors that Determine Extra- versus Intradiol Cleavage.

The extradiol dioxygenases (EDOs) and intradiol dioxygenases (IDOs) are nonheme iron enzymes that catalyze the oxidative aromatic ring cleavage of catechol substrates, playing an essential role in the carbon cycle. The EDOs and IDOs utilize very different FeII and FeIII active sites to catalyze the regiospecificity in their catechol ring cleavage products. The factors governing this difference in cleavage have remained undefined. The EDO homoprotocatechuate 2,3-dioxygenase (HPCD) and IDO protocatechuate 3,4-dioxygenase (PCD) provide an opportunity to understand this selectivity, as key O2 intermediates have been trapped for both enzymes. Nuclear resonance vibrational spectroscopy (in conjunction with density functional theory calculations) is used to define the geometric and electronic structures of these intermediates as FeII-alkylhydroperoxo (HPCD) and FeIII-alkylperoxo (PCD) species. Critically, in both intermediates, the initial peroxo bond orientation is directed toward extradiol product formation. Reaction coordinate calculations were thus performed to evaluate both the extra- and intradiol O-O cleavage for the simple organic alkylhydroperoxo and for the FeII and FeIII metal catalyzed reactions. These results show the FeII-alkylhydroperoxo (EDO) intermediate undergoes facile extradiol O-O bond homolysis due to its extra e-, while for the FeIII-alkylperoxo (IDO) intermediate the extradiol cleavage involves a large barrier and would yield the incorrect extradiol product. This prompted our evaluation of a viable mechanism to rearrange the FeIII-alkylperoxo IDO intermediate for intradiol cleavage, revealing a key role in the rebinding of the displaced Tyr447 ligand in this rearrangement, driven by the proton delivery necessary for O-O bond cleavage.

Attitudes to reducing cervical screening frequency among UK women: A qualitative analysis.

OBJECTIVE: Cervical cancer remains a significant health threat amongst women globally despite most cervical cancers being preventable through screening and Human Papilloma Virus (HPV) vaccination. With the introduction of HPV testing and vaccination, evidence suggests that the frequency of cervical screening for women can be reduced. However, there is limited evidence on women's attitudes to possible changes to the cervical screening programme. This study explored attitudes, perceptions and beliefs of women in the United Kingdom (UK) regarding potential changes to the National Cervical Screening Programme. METHOD: Forty-four women were interviewed between November 2018 and March 2019. Reflexive thematic analysis was used to identify key themes. RESULTS: Most participants were opposed to any reduction in cervical screening frequency. Reasons included perceptions that disease would develop undetected, disempowerment, increased anxiety, reduced motivation to attend, and inefficient use of health care resources. Women perceived that they were ill-informed about the reasons for the proposed change, and that access to evidence for the basis of proposed changes may persuade them to accept reduced screening frequency. Women believed that cervical screening is a test for cancer and that HPV vaccination does not provide reliable protection against cervical cancer. These beliefs suggest that women's perception that they require more information about the basis for reduced screening frequency is correct. CONCLUSION: Any changes to cervical screening frequency need to ensure public support and trust through a robust public health initiative clearly identifying the rationale for any changes.

Advanced practice nursing initiatives in Africa, moving towards the nurse practitioner role: Experiences from the field.

AIM: This paper discusses the development and progression of the advanced practice nurse practitioner role in Africa. BACKGROUND: Providing adequate primary health care is problematic in Africa. The World Health Organization and International Council of Nurses proposed that nurses, specifically advanced practice nurse practitioners with the requisite skills in disease prevention, diagnosis and management, can be key to solving the primary care issue. SOURCES OF EVIDENCE: This paper utilized publications from PUBMED, CINAHL, policy papers, websites, workgroups, conferences, and the experiences and knowledge of authors involved in leading and moving forward key events and projects. DISCUSSION: Four African countries have formally adopted the advanced practice nurse practitioner role, with significant interest from countries throughout Africa, and ever-increasing requests for assistance regarding initiation, development and integration of advanced practice roles. Initiatives to advance the roles have been supported by the International Council of Nurses Nurse Practitioner/Advanced Practice Nurse Network and Global Academy of Research and Enterprise. Next steps and projects for future role development are discussed. CONCLUSIONS: There is a progression towards the adoption of the advanced practice nurse practitioner role in Africa, and further mechanisms are suggested to allow full uptake and utilization. IMPLICATIONS FOR NURSING PRACTICE: Prioritization and investment in initiatives implementing nurse practitioner/advanced practice nurse roles in Africa allows nurses to pursue further education, advanced role and leadership opportunities consistent with Nursing Now goals. IMPLICATIONS FOR HEALTH POLICY: Implementation of nurse practitioner/advanced practice nurse roles increases the primary care workforce, consistent with recommendations and priorities in the World Health Organization Global Strategic Directions for Nursing and Midwifery 2021-2025 helping countries ensure that nurses optimally contribute to achieving universal health coverage and other population health goals.

A global perspective of advanced practice nursing research: A review of systematic reviews protocol.

INTRODUCTION: In 2020, the World Health Organization called for the expansion and greater recognition of all nursing roles, including advanced practice nurses (APNs), to better meet patient care needs. As defined by the International Council of Nurses (ICN), the two most common APN roles include nurse practitioners (NPs) and clinical nurse specialists (CNSs). They help ensure care to communities as well as patients and families with acute, chronic or complex conditions. Moreover, APNs support providers to deliver high quality care and improve access to services. Currently, there is much variability in the use of advanced practice nursing roles globally. A clearer understanding of the roles that are in place across the globe, and how they are being used will support greater role harmonization, and inform global priorities for advanced practice nursing education, research, and policy reform. OBJECTIVE: To identify current gaps in advanced practice nursing research globally. MATERIALS AND METHODS: This review of systematic reviews will provide a description of the current state of the research, including gaps, on advanced practice nursing globally. We will include reviews that examine APNs, NPs or CNSs using recognized role definitions. We will search the CINAHL, EMBASE, Global Health, HealthStar, PubMed, Medline, Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects, Joanna Briggs Institute, and Web of Science electronic databases for reviews published from January 2011 onwards, with no restrictions on jurisdiction or language. We will search the grey literature and hand search the reference lists of all relevant reviews to identify additional studies. We will extract country, patient, provider, health system, educational, and policy/scope of practice data. We will assess the quality of each included review using the CASP criteria, and summarize their findings. This review of systematic reviews protocol was developed following the PRISMA-P recommendations. PROSPERO REGISTRATION NUMBER: CRD42021278532.

Contrasting Mechanisms of Aromatic and Aryl-Methyl Substituent Hydroxylation by the Rieske Monooxygenase Salicylate 5-Hydroxylase.

The hydroxylase component (S5HH) of salicylate-5-hydroxylase catalyzes C5 ring hydroxylation of salicylate but switches to methyl hydroxylation when a C5 methyl substituent is present. The use of 18O2 reveals that both aromatic and aryl-methyl hydroxylations result from monooxygenase chemistry. The functional unit of S5HH comprises a nonheme Fe(II) site located 12 Šacross a subunit boundary from a one-electron reduced Rieske-type iron-sulfur cluster. Past studies determined that substrates bind near the Fe(II), followed by O2 binding to the iron to initiate catalysis. Stopped-flow-single-turnover reactions (STOs) demonstrated that the Rieske cluster transfers an electron to the iron site during catalysis. It is shown here that fluorine ring substituents decrease the rate constant for Rieske electron transfer, implying a prior reaction of an Fe(III)-superoxo intermediate with a substrate. We propose that the iron becomes fully oxidized in the resulting Fe(III)-peroxo-substrate-radical intermediate, allowing Rieske electron transfer to occur. STO using 5-CD3-salicylate-d8 occurs with an inverse kinetic isotope effect (KIE). In contrast, STO of a 1:1 mixture of unlabeled and 5-CD3-salicylate-d8 yields a normal product isotope effect. It is proposed that aromatic and aryl-methyl hydroxylation reactions both begin with the Fe(III)-superoxo reaction with a ring carbon, yielding the inverse KIE due to sp2 → sp3 carbon hybridization. After Rieske electron transfer, the resulting Fe(III)-peroxo-salicylate intermediate can continue to aromatic hydroxylation, whereas the equivalent aryl-methyl intermediate formation must be reversible to allow the substrate exchange necessary to yield a normal product isotope effect. The resulting Fe(III)-(hydro)peroxo intermediate may be reactive or evolve through a high-valent iron intermediate to complete the aryl-methyl hydroxylation.

Dynamic Long-Range Interactions Influence Substrate Binding and Catalysis by Human Histidine Triad Nucleotide-Binding Proteins (HINTs), Key Regulators of Multiple Cellular Processes and Activators of Antiviral ProTides.

Human histidine triad nucleotide-binding (hHINT) proteins catalyze nucleotide phosphoramidase and acyl-phosphatase reactions that are essential for the activation of antiviral proTides, such as Sofosbuvir and Remdesivir. hHINT1 and hHINT2 are highly homologous but exhibit disparate roles as regulators of opioid tolerance (hHINT1) and mitochondrial activity (hHINT2). NMR studies of hHINT1 reveal a pair of dynamic surface residues (Q62, E100), which gate a conserved water channel leading to the active site 13 Å away. hHINT2 crystal structures identify analogous residues (R99, D137) and water channel. hHINT1 Q62 variants significantly alter the steady-state kcat and Km for turnover of the fluorescent substrate (TpAd), while stopped-flow kinetics indicate that KD also changes. hHINT2, like hHINT1, exhibits a burst phase of adenylation, monitored by fluorescent tryptamine release, prior to rate-limiting hydrolysis and nucleotide release. hHINT2 exhibits a much smaller burst-phase amplitude than hHINT1, which is further diminished in hHINT2 R99Q. Kinetic simulations suggest that amplitude variations can be accounted for by a variable fluorescent yield of the E·S complex from changes in the environment of bound TpAd. Isothermal titration calorimetry measurements of inhibitor binding show that these hHINT variants also alter the thermodynamic binding profile. We propose that these altered surface residues engender long-range dynamic changes that affect the orientation of bound ligands, altering the thermodynamic and kinetic characteristics of hHINT active site function. Thus, studies of the cellular roles and proTide activation potential by hHINTs should consider the importance of long-range interactions and possible protein binding surfaces far from the active site.

"A lot can happen in five years": Women's attitudes to extending cervical screening intervals.

OBJECTIVE: Evidence suggests that cervical screening intervals can be extended and lifetime cervical screening for human papillomavirus (HPV)-vaccinated women could be reduced. This study examines UK women's attitudes to extending screening intervals and assesses associations between knowledge, risk perception and HPV vaccination status, and acceptability of changes. METHODS: Using a convenience sampling strategy, an anonymous mixed-methods online survey was used and data recorded from 647 women (mean age = 28.63, SD = 8.69). RESULTS: Across the full sample, 46.1% of women indicated they would wait 5 years for their next cervical screening, while 60.2% of HPV-vaccinated women would be unwilling to have as few as three cervical screens in a lifetime. Multivariate analysis revealed those who are regular screened, those who intend to attend when invited, and those who perceive greater personal risk of cervical cancer are less likely to accept a 5-year screening interval. Qualitative findings relating to benefits of extending intervals included convenience of less tests, less physical discomfort, and psychological distress. Concerns identified included the likelihood of developing illness, increased psychological distress relating to what may be happening in the body, and worries about increased risk of cervical cancer. CONCLUSION: Women need clear and specific information about HPV timelines, their relationship with cancer risk, and the rationale for extending screening intervals.

Emotional well-being, spiritual well-being and resilience of advanced clinical practitioners in the United Kingdom during COVID-19: an exploratory mixed method study.

AIM: To investigate the emotional and spiritual well-being and resilience of advanced clinical practitioners during COVID. BACKGROUND: Resilience is a protective factor for emotional and spiritual well-being. The pandemic has taken a toll on health professionals due to significant physical and psychological pressures. The impact of COVID-19 on well-being and resilience of advanced clinical practitioners is not known. METHOD: Three validated scales assessed resilience, emotional and spiritual well-being. Seven hundred and thirty-four responses were analysed. RESULTS: Participants have low levels of emotional and spiritual well-being. Participants with higher levels of spirituality reported greater resilience and those with higher levels of resilience reported greater well-being. CONCLUSION: Advanced clinical practitioners' emotional and spiritual well-being and resilience has been impacted significantly during the pandemic. Interventions are needed at team, service and systems levels to enhance well-being and resilience. IMPLICATIONS FOR NURSING MANAGEMENT: Worryingly low levels of well-being and resilience in advanced clinical practitioners have been found; support to increase well-being and resilience is needed. Our findings can inform policies, resources and interventions aimed at enabling positive adaptation and enhanced resilience. Understanding and responding to the scale and impact of COVID-19 on health care workers has become a key government recommendation following the pandemic.

An examination of student nurse practitioners' diagnostic reasoning skills.

AIM: To examine the diagnostic reasoning skills of two nurse practitioner student cohorts. INTRODUCTION: Nurse practitioners continue to play a pivotal role in health care provision. Diagnostic reasoning is a core skill of advanced practice. A comparative diagnostic reasoning study between two student cohorts was undertaken between 2018 and 2019. METHODS: A validated diagnostic reasoning scale was completed by nurse practitioner students in the United Kingdom and the United States of America at the beginning and end of their clinical placements. The study utilized descriptive quantitative statistics from the data submitted by 22 survey respondents from an online survey. RESULTS: Analysis of the diagnostic reasoning skills suggested there was a difference in the structural memory scores when compared with the beginning of their clinical placements and the final semester of their clinical placements. CONCLUSION: Diagnostic reasoning skills are a core skill of advanced practice. As students progress through their training, these skills improve. Despite the statistical difference in diagnostic reasoning scores, caution should be made in determining any larger implications due to the small number of participants in this study. Further study is needed in this area.

Global emotional and spiritual well-being and resilience of Advanced Practice Nurses during the COVID-19 pandemic: A cross-sectional study.

AIM: To evaluate the impact of the COVID-19 pandemic on the emotional and spiritual well-being and resilience of a global sample of Advanced Practice Nurses. DESIGN: A web-based cross-sectional mixed methods study. Survey data were collected from Advanced Practice Nurses globally over a 2-month period ending on 31 August 2020. METHODS: The Warwick-Edinburgh Mental Well-being Scale, FACIT-12 Spiritual Well-being Scale and Connor-Davidson Resilience Scale 10 were used to quantify emotional and spiritual well-being and resilience of Advanced Practice Nurses' globally. The survey was distributed internationally using snowball sampling via a secure platform (Qualtrics). Results were analysed using various bivariate tests for associations and group differences. RESULTS: Nine hundred and twenty-eight Advanced Practice Nurses from 53 countries participated in the study. Study participants reported meaningfully lower scores in resilience and emotional well-being compared with non-pandemic scores. Participants from countries with well-developed Advanced Practice Nurses roles reported lower resilience and well-being scores compared with those from countries where Advanced Practice Nurses roles are still being developed. Each scale revealed significant positive associations with the other scales. CONCLUSIONS: Emotional and spiritual well-being and resilience of Advance Practice Nurses has been significantly impacted during the COVID-19 pandemic. Regardless of their work location, work hours, credential or demographics, the APNs in our study reported lower levels of resilience and mental well-being compared with typical scores on the instruments.

Evaluation of an international program for nurse practitioner students.

BACKGROUND: There are few opportunities for nurse practitioner (NP) students to develop relationships and exchange ideas with international counterparts. In addition, discovering differences in instructional pedagogy between programs is beneficial for every student. PURPOSE: To facilitate an international understanding of health care services and compare curricula of advanced practice programs through an international experience for first year NP students from the United Kingdom and the United States. METHODOLOGICAL ORIENTATION: The study used a qualitative analysis of responses from specified questions provided to both cohorts of students before and after the experience. SAMPLE: A virtual global exchange between 23 advanced practice students and their professors in the spring of 2018 culminated in a trip by the UK students and faculty to the United States in April of that year. CONCLUSIONS: The UK and US NP students positively evaluated the international encounter and pointed out specific educational activities that were most helpful to their training. IMPLICATIONS FOR PRACTICE: International experiences offer NP students the opportunity to experience health care delivery in an alternative cultural milieu.

6-phenylpyrrolocytosine as a fluorescent probe to examine nucleotide flipping catalyzed by a DNA repair protein.

Cellular exposure to tobacco-specific nitrosamines causes formation of promutagenic O6 -[4-oxo-4-(3-pyridyl)but-1-yl]guanine (O6 -POB-G) and O6 -methylguanine (O6 -Me-G) adducts in DNA. These adducts can be directly repaired by O6 -alkylguanine-DNA alkyltransferase (AGT). Repair begins by flipping the damaged base out of the DNA helix. AGT binding and base-flipping have been previously studied using pyrrolocytosine as a fluorescent probe paired to the O6 -alkylguanine lesion, but low fluorescence yield limited the resolution of steps in the repair process. Here, we utilize the highly fluorescent 6-phenylpyrrolo-2'-deoxycytidine (6-phenylpyrrolo-C) to investigate AGT-DNA interactions. Synthetic oligodeoxynucleotide duplexes containing O6 -POB-G and O6 -Me-G adducts were placed within the CpG sites of codons 158, 245, and 248 of the p53 tumor suppressor gene and base-paired to 6-phenylpyrrolo-C in the opposite strand. Neighboring cytosine was either unmethylated or methylated. Stopped-flow fluorescence measurements were performed by mixing the DNA duplexes with C145A or R128G AGT variants. We observe a rapid, two-step, nearly irreversible binding of AGT to DNA followed by two slower steps, one of which is base-flipping. Placing 5-methylcytosine immediately 5' to the alkylated guanosine causes a reduction in rate constant of nucleotide flipping. O6 -POB-G at codon 158 decreased the base flipping rate constant by 3.5-fold compared with O6 -Me-G at the same position. A similar effect was not observed at other codons.

[The spiritual dimension in nursing]. / La dimension spirituelle dans les soins infirmiers.

Spirituality refers to that which gives us hope, meaning and purpose. It is naturally part of the holistic nature of the care provided by nurses to people going through life's challenges: health-related accident, serious and incurable illness, chronic disease, end of life, etc. A British advanced practice nurse, who has enriched her training with a doctorate in spirituality in the context of health care, enlightens this dimension, which is less formalized in France than in the United Kingdom, and suggests resources for progressing personally and professionally.

Understanding the role of spirituality in providing person-centred care.

An awareness of the concept of spirituality is integral to the provision of person-centred holistic care. However, the nurse's ability to provide spiritual care is often impeded by time pressures and the prioritisation of clinical tasks. Confusion about the meaning of spirituality and its relationship to religion may also compound the challenges involved in providing spiritual care, and nurses often feel ill-equipped to address this area of care. This article discusses the challenges associated with the concept of spirituality, and describes the competencies and personal qualities that nurses require to achieve spiritually competent practice. It also explains the concepts of availability and vulnerability, which can support the personal development required for nurses to become spiritually competent.

Spiritual Dimensions of Nurse Practitioner Consultations in Family Practice.

Purpose of Study: To explore the spiritual dimensions of nurse practitioner consultations in primary care through the lens of availability and vulnerability. Design of Study and Methods Used: A hermeneutic phenomenological enquiry exploring the spiritual dimensions of primary care consultations consisting of two interviews per participant over an 18-month period was conducted with nurse practitioners in the United Kingdom. A purposive sample of eight nurse practitioners were recruited and interviewed. Interviews were fully transcribed and analyzed thematically. Findings: Participants identified that spirituality can be difficult to conceptualize and operationalize in practice. Participants articulated the meaning of spirituality and gave examples of when they had witnessed a spiritual dimension in practice. Key themes included how nurse practitioners conceptualize spirituality, the context for spirituality to be integrated into care, and the importance of spirituality as an aspect of holistic care. The concepts of Availability and Vulnerability were used intentionally as a lens in the study to explore whether these concepts and approaches to practice could enhance integration of spirituality into practice. Conclusion: Knowledge and understanding regarding spirituality in nurse practitioners consultations in primary care has been uncovered. A framework for operationalizing spirituality has been developed.

A questionnaire-based study of attitudes to spirituality in mental health practitioners and the relevance of the concept of spiritually competent care.

In the light of the increasing recognition of the relevance of spirituality in person-centred, holistic care, this study examines the attitudes of a convenience sample of mental health practitioners, including nurses, to the concepts of spirituality in general and in clinical practice. A series of 5-point Likert-style items assessed two key domains of spirituality in everyday life (SEDL) and spirituality in practice (SIP). The questionnaire was derived from one previously used with healthcare educators (including nurses). Each item was scored from 1 point (strongly disagree) to 5 points (strongly agree). Additional information about how far practitioners believed spirituality had been integrated in their education and how much they believed that spirituality related to religion was also ascertained. Three further items, not part of the main questionnaire, dealt with respondents' views of spirituality competent practice, in the light of a description provided as part of the questionnaire. Data were collected from 104 respondents. Standard statistical procedures, including reliability analyses, were applied to the data. Respondents who viewed spirituality to be distinct from religion, or a place of worship, were likely to place a higher value on spirituality in everyday life, while respondents who experienced the integration of spirituality within their preregistration training and/or clinical education were likely to place a higher value on the place of spirituality in practice. The possible reasons for these associations are discussed in the light of the importance of spiritual care as a part of person-centred, holistic practice.