Mobilizing nurses to address the opioid misuse epidemic.

BACKGROUND: The opioid epidemic is a major health challenge in the United States. PURPOSE: Members from the American Academy of Nursing joined to write a consensus paper about nurses' role in the opioid epidemic. METHODS: The panel reviewed the history of the opioid epidemic and policies to care for patients with opioid use disorder (OUD) and how registered nurses (RNs) and advanced practice nurses (APRNs) could increase care for people with OUD. DISCUSSION: Recommendations are presented to advance policies that empower RNs and APRNs to abate the opioid epidemic. CONCLUSION: Recommendations include (a) advance legislation that supports RNs and APRNs full scope of practice and expands professional role in pain management and addiction prevention; (b) evaluate effective policies that promote RN and APRN care; support federal elimination of X-waiver with state law alignment; (c) sustain the use of nurses in telemedicine; (d) support nursing research on nurse involvement in all aspects of OUD.

American Academy of Nursing consensus recommendations to advance system level change for nurse well-being.

The COVID-19 pandemic has required close examination of workforce-related stressors that over decades have contributed to widespread burnout, negative health outcomes, including mental health outcomes, and the loss of the well-educated professionals who are the future of the nursing profession. In the United States and globally, evidence points to factors known to diminish well-being, including inequities, issues of minority status, persistent discrimination, and demanding work environments. The American Academy of Nursing (AAN), dedicated to organizational excellence, nursing leadership and evidence-based policy, develops statements reflecting its mission and those of its nursing affiliates and corporate member, The American Nurses Association. Within nursing, despite the efforts of its members toward advancement, professional fulfillment is often constrained by the systems in which nurses practice and workplace factors over which they have little control. Action by key organizations to initiate changes at systems levels in workplace safety, to increase professional mobility, and propel policies that increase access to health care resources could improve nurse well-being. This paper proposes recommendations from the AAN Expert Panels on Building Health Care System Excellence, Psychiatric Mental Health and Substance Use, and Global Health Expert Panels for the American Academy of Nursing to leverage related policy in the arenas of government and professional/healthcare organizations. Transforming health care work environments and advancing nurse well-being and equity can be accomplished through key, innovative policy changes. These will be achieved through collaboration among associations, organizations, nonprofit groups, and with the public and the media.

Perceptions of Teamwork in Schools of Nursing.

BACKGROUND: Characteristics of high-performing teams include shared purpose, clear vision, strong leadership, and the ability to use conflict management when needed. While many individuals who teach in schools of nursing come from the clinical setting where teamwork is normative, that same expectation of teamwork may not be present for the faculty as a whole. PURPOSE: This study assessed perceptions of teamwork among faculty members in schools of nursing in 4 states in the Midwestern region of the United States. METHODS: Perception of teamwork, related to communication, leadership, team structure, situation monitoring, and mutual support, was examined using a modified TeamSTEPPS Teamwork Perceptions Questionnaire. RESULTS: Perceptions of teamwork were highest for team structure and leadership, whereas communication, situation monitoring, and mutual support were lower. In addition, teamwork dimension scores were higher for those who previously participated in teamwork training. CONCLUSIONS: There are opportunities to improve teamwork in all domains. Teamwork skills are transferrable to different roles and across various situations; therefore once learned and fostered, these can impact the individual as well as improve the organizational climate.

Improving Teamwork and Communication in Schools of Nursing: A Quality Improvement Approach Using TeamSTEPPS.

BACKGROUND: Teamwork training has been identified as an intervention to promote collaboration, improve communication, and reduce conflict. While teamwork training has been implemented in the clinical setting, most schools of nursing are lacking in standardized teamwork training programs. LOCAL PROBLEM: A lack of teamwork, poor communication, and deficient conflict resolution skills among faculty and staff was impacting the ability to form supportive relationships in the interest of working collaboratively. METHODS: This quality improvement (QI) project examined perceptions of teamwork at 3 points over 18 months. INTERVENTION: Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was adapted for the academic setting and used for the intervention. RESULTS: Results indicated significant improvement in Team Structure, Leadership, and Communication. Situation Monitoring and Mutual Support were identified for continued development. CONCLUSION: Results suggest that a QI intervention using TeamSTEPPS improved teamwork, communication, collaboration, and conflict resolution in one academic setting.

The Effective Use of Psychiatric Mental Health Nurses in Integrated Care: Policy Implications for Increasing Quality and Access to Care.

In the last ten years primary care providers have been encouraged to implement integrated models of care where individuals' medical and mental health needs are addressed holistically. Many integrated models use Psychiatric Mental Health (PMH) nurses as case managers and select exemplars use PMH Advanced Practice Nurses (APNs) as providers. However, the potential value of PMH nurses in integrated health care remains unrealized by health care planners and payers, limiting access to services for the populations most in need of comprehensive care approaches. This current situation is partially fueled by insufficient knowledge of the roles and skill sets of PMH nurses. In this paper, the PMH RN and APN skill sets are detailed, demonstrating how effective use of these nurses can further the aims of integrated care models. Finally, outlined are barriers and enabling factors to effective use of PMH RNs and APNs and attendant policy implications.

Preparing the Workforce for Behavioral Health and Primary Care Integration.

PURPOSE: To identify how organizations prepare clinicians to work together to integrate behavioral health and primary care. METHODS: Observational cross-case comparison study of 19 U.S. practices, 11 participating in Advancing Care Together, and 8 from the Integration Workforce Study. Practices varied in size, ownership, geographic location, and experience delivering integrated care. Multidisciplinary teams collected data (field notes from direct practice observations, semistructured interviews, and online diaries as reported by practice leaders) and then analyzed the data using a grounded theory approach. RESULTS: Organizations had difficulty finding clinicians possessing the skills and experience necessary for working in an integrated practice. Practices newer to integration underestimated the time and resources needed to train and organizationally socialize (onboard) new clinicians. Through trial and error, practices learned that clinicians needed relevant training to work effectively as integrated care teams. Training efforts exclusively targeting behavioral health clinicians (BHCs) and new employees were incomplete if primary care clinicians (PCCs) and others in the practice also lacked experience working with BHCs and delivering integrated care. Organizations' methods for addressing employees' need for additional preparation included hiring a consultant to provide training, sending employees to external training programs, hosting residency or practicum training programs, or creating their own internal training program. Onboarding new employees through the development of training manuals; extensive shadowing processes; and protecting time for ongoing education, mentoring, and support opportunities for new and established clinicians and staff were featured in these internal training programs. CONCLUSION: Insufficient training capacity and practical experience opportunities continue to be major barriers to supplying the workforce needed for effective behavioral health and primary care integration. Until the training capacity grows to meet the demand, practices must put forth considerable effort and resources to train their own employees.

Protein markers for identification of Yersinia pestis and their variation related to culture.

The detection of high consequence pathogens, such as Yersinia pestis, is well established in biodefense laboratories for bioterror situations. Laboratory protocols are well established using specified culture media and a growth temperature of 37 °C for expression of specific antigens. Direct detection of Y. pestis protein markers, without prior culture, depends on their expression. Unfortunately protein expression can be impacted by the culture medium which cannot be predicted ahead of time. Furthermore, higher biomass yields are obtained at the optimal growth temperature (i.e. 28 °C-30 °C) and therefore are more likely to be used for bulk production. Analysis of Y. pestis grown on several types of media at 30 °C showed that several protein markers were found to be differentially detected in different media. Analysis of the identified proteins against a comprehensive database provided an additional level of organism identification. Peptides corresponding to variable regions of some proteins could separate large groups of strains and aid in organism identification. This work illustrates the need to understand variability of protein expression for detection targets. The potential for relating expression changes of known proteins to specific media factors, even in nutrient rich and chemically complex culture medium, may provide the opportunity to draw forensic information from protein profiles.

Characterization of residual medium peptides from Yersinia pestis cultures.

Here we demonstrate that when Yersinia pesitis is grown in laboratory media, peptides from the medium remain associated with cellular biomass even after washing and inactivation of the bacteria by different methods. These peptides are characteristic of the type of growth medium and of the manufacturer of the medium, reflecting the specific composition of the medium. We analyzed biomass-associated peptides from cultures of two attenuated strains of Yersinia pestis [KIM D27 (pgm-) and KIM D1 (lcr-)] grown in several formulations of 4 different media (tryptic soy broth (TSB), brain-heart infusion (BHI), Luria-Bertani broth (LB), and glucose (G) medium) made from components purchased from different suppliers. Despite the range of growth medium sources and the associated manufacturing processes used in their production, a high degree of peptide similarity was observed for a given medium recipe; however, notable differences in the termination points of select peptides were observed in media formulated using products from some suppliers, presumably reflecting the process by which a manufacturer performed protein hydrolysis for use in culture media. These results may help explain the presence of peptides not explicitly associated with target organisms during proteomic analysis of microbes and other biological systems that require culturing. While the primary aim of this work is to outline the range and type of medium peptides associated with Yersinia pestis biomass and improve the quality of proteomic measurements, these peptides may also represent a potentially useful forensic signature that could provide information about microbial culturing conditions.

Communicating nursing's excellence and value: on the way to Magnet.

Effective communication is essential as nurses convey their critical impact in care delivery. As part of Magnet readiness, the Main Line Health System engaged a nationally recognized expert to develop a communications strategy for staff nurses and front-line managers. This initiative was driven by the chief nursing officer and the nursing leadership team. The goal was to refine communication skills of the nursing staff to tell their story of the Magnet work achieved as well as to better prepare staff to clearly articulate the essential elements of their work in all settings. The result was clinical nurses who were able to articulate their unique value in a changing health care world clearly.

The nursing quality partnership: building a health system approach to improving care in community hospitals using principles of the magnet program of excellence.

Review of the Magnet Recognition Program journey related to the partnership between nursing and quality in building a comprehensive, results-driven quality and safety program in a 5 hospital community system in suburban Philadelphia over a 5-year period (2006-2011).

Determination of post-culture processing with carbohydrates by MALDI-MS and TMS derivatization GC-MS.

Biological materials generally require stabilization to retain activity or viability in a dry form. A number of industrial products, such as vaccines, probiotics and biopesticides have been produced as dry preparations. The same methods and materials used for stabilizing commercial microbial products may be applicable to preserving biothreat pathogens in a dry form. This is a likely step that may be encountered when looking at samples from terrorism attempts since only spores, such as those from Bacillus anthracis, are inherently stable when dried. The stabilizers for microbial preparations generally include one or more small carbohydrates. Different formulations have been reported for different industrial products and are often determined empirically. However sugar alcohols (mannitol and sorbitol) and disaccharides (lactose, sucrose and trehalose) are the common constituents of these formulations. We have developed an analytical method for sample preparation and detection of these simple carbohydrates using two complementary analytical tools, MALDI-MS and GC-MS. The native carbohydrates and other constituents of the formulation are detected by MALDI-MS as a screening tool. A longer and more detailed analysis is then used to specifically identify the carbohydrates by derivatization and GC-MS detection. Both techniques were tested against ten different types of stabilization recipes with Yersinia pestis cell mass cultured on different media types used as the biological component. A number of additional components were included in these formulations including proteins and peptides from serum or milk, polymers (e.g. poly vinyl pyrrolidone - PVP) and detergents (e.g. Tween). The combined method was characterized to determine several figures of merit. The accuracy of the method was 98% for MALDI-MS and 100% for GC-MS. The repeatability for detection of carbohydrates by MALDI-MS was determined to be 96%. The repeatability of compound identification by GC-MS was determined by monitoring variation in retention time, which is vital for identification of isomeric carbohydrates. The figures of merit illustrate an effective and accurate method for mono and disaccharide detection independent of formulation. This meets our primary goal for method development as small carbohydrates are among the most common stabilizers employed.

Human norovirus infection of caco-2 cells grown as a three-dimensional tissue structure.

Human norovirus (hNoV) infectivity was studied using a three-dimensional model of large intestinal epithelium. Large intestine Caco-2 cells were grown in rotating wall vessel bioreactors for 18-21 days at 37 degrees C and then transferred to 24-well tissue culture plates where they were infected with GI.1 and GII.4 human noroviruses collected from human challenge trials and various outbreak settings, respectively. Compared with uninfected cells, transmission micrographs of norovirus-infected cells displayed evidence of shortening or total loss of apical microvilli, and vacuolization. Quantitative reverse transcription real-time PCR (qRT-PCR) indicated an approximate 2-3 log10 increase in viral RNA copies for the infected cells. A passage experiment examined both the ability for continued viral RNA and viral antigen detection. In the passaged samples 1.01x10(6) copies ml(-1) were detected by qRT-PCR. Immune electron microscopy using primary antibody to hNoV GI.1 capsids in conjunction with 6 nm gold-labelled secondary antibodies was performed on crude cellular lysates. Localization of antibody was observed in infected but not for uninfected cells. Our present findings, coupled with earlier work with the three-dimensional small intestinal INT407 model, demonstrate the utility of 3-D cell culture methods to develop infectivity assays for enteric viruses that do not readily infect mammalian cell cultures.

The CNO/CFO partnership: navigating the changing landscape.

With increasing pressure to cut costs, both real and immediate, and those forecasted and anticipated, the partnership and collaboration between nursing and finance will continue to take on new challenges. This partnership has historically been strained and does not always come easy due to differences in focus, different priorities, and inadequate communication, listening, and hearing. That needs to change and a strong CNO-CFO partnership is needed. Nursing leaders need to understand and appreciate the financial constraints and balance them with expected outcomes, and financial leaders need to understand and appreciate the core clinical business and what gaps in care mean to the financial viability of the organization and to patient outcomes. One health system developed a platform for change and is dedicated to the hard work involved in continuously working on those partnerships so when it comes to patient quality, safety, and financial performance, nursing and finance leaders are well positioned for future health care challenges.

The effect of growth medium on B. anthracis Sterne spore carbohydrate content.

The expressed characteristics of biothreat agents may be impacted by variations in the culture environment, including growth medium formulation. The carbohydrate composition of B. anthracis spores has been well studied, particularly for the exosporium, which is the outermost spore structure. The carbohydrate composition of the exosporium has been demonstrated to be distinct from the vegetative form containing unique monosaccharides. We have investigated the carbohydrate composition of B. anthracis Sterne spores produced using four different medium types formulated with different sources of medium components. The amount of rhamnose, 3-O-methyl rhamnose and galactosamine was found to vary significantly between spores cultured using different medium formulations. The relative abundance of these monosaccharides compared to other monosaccharides such as mannosamine was also found to vary with medium type. Specific medium components were also found to impact the carbohydrate profile. Xylose has not been previously described in B. anthracis spores but was detected at low levels in two media. This may represent residual material from the brewery yeast extract used to formulate these two media. These results illustrate the utility of this method to capture the impact of growth medium on carbohydrate variation in spores. Detecting carbohydrate profiles in B. anthracis evidentiary material may provide useful forensic information on the growth medium used for sporulation.

Preservation of viable Francisella tularensis for forensic analysis.

As a preservation solution, (1%) ammonium chloride may be preferred over other conventionally used storage solutions because of its compatibility with analytical techniques such as Mass Spectrometry. In this study, ammonium chloride performed as well or better than phosphate buffered saline with Tween or Butterfields/Tween for preserving Francisella tularensis subsp. novicida.

Residual agar determination in bacterial spores by electrospray ionization mass spectrometry.

Presented here is an analytical method to detect residual agar from a bacterial spore sample as an indication of culturing on an agar plate. This method is based on the resolubilization of agar polysaccharide from a bacterial spore sample, enzymatic digestion, followed by electrospray ionization tandem mass spectrometry (ESI-MS(n)) analysis for detection of a specific agar fragment ion. A range of Bacillus species and strains were selected to demonstrate the effectiveness of this approach. The characteristic agar fragment ion was detected in the spores grown on agar that were washed from 1 to 5 times, irradiated or nonirradiated, and not in the spores grown in broth. A sample containing approximately 10(8) spores is currently needed for confident detection of residual agar from culture on agar plates in the presence of bacterial spores with a limit of detection of approximately 1 ppm agar spiked into a broth-grown spore sample. The results of a proficiency test with 42 blinded samples are presented demonstrating the utility of this method with no false positives and only three false negatives for samples that were below the detection level of the method as documented.

Chemometric analysis of multiple species of Bacillus bacterial endospores using infrared spectroscopy: discrimination to the strain level.

Previous work using infrared spectroscopy has shown potential for rapid discrimination between bacteria in either their sporulated or vegetative states, as well as between bacteria and other common interferents. For species within one physiological state, however, distinction is far more challenging, and requires chemometrics. In the current study, we have narrowed the field of study by eliminating the confounding issues of vegetative cells as well as growth media and focused on using IR spectra to distinguish only between different species all in the sporulated state. Using principal component analysis (PCA) and a classification method based upon similarity measurements, we demonstrate a successful identification rate to the species level of 85% for Bacillus spores grown and sporulated in a glucose broth medium.

The infrared spectra of Bacillus bacteria part I: vegetative Bacillus versus sporulated cells and the contributions of phospholipids to vegetative infrared spectra.

This paper highlights the distinctions between the infrared (IR) absorption spectra of vegetative versus sporulated Bacillus bacteria. It is observed that there are unique signatures clearly associated with either the sporulated or vegetative state and that vegetative cells (or cell debris) can contribute to the spore spectra. A distinct feature at approximately 1739 cm(-1) appears to be unique to vegetative cell spectra and can also be used as an indicator of vegetative cells or cell debris in the spore spectra. The data indicate that the band arises from a lipid-soluble species such as an ester or phospholipid carbonyl bond and are consistent with it being either phosphatidyl glycerol (PG) or phosphatidylethanolamine (PE), two major classes of phospholipids found in vegetative cells of Bacillus species. A companion work discusses bands associated with the sporulated state.

The infrared spectra of Bacillus bacteria part II: sporulated Bacillus--the effect of vegetative cells and contributions of calcium dipicolinate trihydrate, CaDP.3H2O.

Our previous paper showed that certain infrared (IR) peaks, e.g., the peak at 1739 cm(-1), are due to varying (trace) amounts of vegetative cells amongst the Bacillus spores and that these and other vegetative bands are associated with lipid-soluble compounds, likely an ester or phospholipid. This work investigates the infrared spectra of eight different sporulated Bacillus bacteria. For the endospores it is observed that peaks at 1441, 1277, and 1015 cm(-1) along with a distinct quartet of peaks at 766, 725, 701, and 659 cm(-1) are clearly associated with calcium dipicolinate trihydrate, CaDP.3H2O. It is emphasized that the spore peaks, especially the quartet, arise from the calcium dipicolinate trihydrate and not from dipicolinic acid or other dipicolinate hydrate salts. The CaDP.3H2O infrared peaks and the effects of hydration are studied using quantum chemistry in the PQS software package. The quartet is associated with many modes including contributions from the Ca2+ counterion and hydration waters including Ca-O-H bends, H2O-Ca-O torsions, and O-C-O bends. The 1441 and 1015 cm(-1) modes are planar pyridine modes with the 1441 cm(-1) mode primarily a ring C-N stretch and the 1015 cm(-1) mode primarily a ring C-C stretch.