Historic and bioarchaeological evidence supports late onset of post-Columbian epidemics in Native California.

Catastrophic decline of Indigenous populations in the Americas following European contact is one of the most severe demographic events in the history of humanity, but uncertainty persists about the timing and scale of the collapse, which has implications for not only Indigenous history but also the understanding of historical ecology. A long-standing hypothesis that a continent-wide pandemic broke out immediately upon the arrival of Spanish seafarers has been challenged in recent years by a model of regional epidemics erupting asynchronously, causing different rates of population decline in different areas. Some researchers have suggested that, in California, significant depopulation occurred during the first two centuries of the post-Columbus era, which led to a "rebound" in native flora and fauna by the time of sustained European contact after 1769. Here, we combine a comprehensive prehistoric osteological dataset (n = 10,256 individuals) with historic mission mortuary records (n = 23,459 individuals) that together span from 3050 cal BC to AD 1870 to systematically evaluate changes in mortality over time by constructing life tables and conducting survival analysis of age-at-death records. Results show that a dramatic shift in the shape of mortality risk consistent with a plague-like population structure began only after sustained contact with European invaders, when permanent Spanish settlements and missions were established ca. AD 1770. These declines reflect the syndemic effects of newly introduced diseases and the severe cultural disruption of Indigenous lifeways by the Spanish colonial system.

Describing Medication Administration and Alert Patterns Experienced by New Graduate Nurses During the First Year of Practice.

The aim of this study was to describe medication administration and alert patterns among a cohort of new graduate nurses over the first year of practice. Medical errors related to clinical decision-making, including medication administration errors, may occur more frequently among new graduate nurses. To better understand nursing workflow and documentation workload in today's clinical environment, it is important to understand patterns of medication administration and alert generation during barcode-assisted medication administration. Study objectives were addressed through a descriptive, longitudinal, observational cohort design using secondary data analysis. Set in a large, urban medical center in the United States, the study sample included 132 new graduate nurses who worked on adult, inpatient units and administered medication using barcode-assisted medication administration. Data were collected through electronic health record and administration sources. New graduate nurses in the sample experienced a total of 587 879 alert and medication administration encounters, administering 772 unique medications to 17 388 unique patients. Nurses experienced an average medication workload of 28.09 medications per shift, 3.98% of which were associated with alerts, over their first year of practice. In addition to high volume of medication administration, new graduate nurses administer many different types of medications and are exposed to numerous alerts while using barcode-assisted medication administration.

Factors Influencing Medication Administration Outcomes Among New Graduate Nurses Using Bar Code-Assisted Medication Administration.

Paramount to patient safety is the ability for nurses to make clinical decisions free from human error. Yet, the dynamic clinical environment in which nurses work is characterized by uncertainty, urgency, and high consequence, necessitating that nurses make quick and critical decisions. The aim of this study was to examine the influence of human and environmental factors on the decision to administer among new graduate nurses in response to alert generation during bar code-assisted medication administration. The design for this study was a descriptive, longitudinal, observational cohort design using EHR audit log and administrative data. The study was set at a large, urban medical center in the United States and included 132 new graduate nurses who worked on adult, inpatient units. Research variables included human and environmental factors. Data analysis included descriptive and inferential analyses. This study found that participants continued with administration of a medication in 90.75% of alert encounters. When considering the response to an alert, residency cohort, alert category, and previous exposure variables were associated with the decision to proceed with administration. It is important to continue to study factors that influence nurses' decision-making, particularly during the process of medication administration, to improve patient safety and outcomes.

A realist model for home visitation program evaluation.

Increased attention on home visitation as a strategy to reduce child maltreatment and increased funding to support home visitation programs has led to their rapid and widespread adoption in the United States and internationally. The rapid adoption of home visitation programs has occurred without an adequate understanding of the underlying mechanisms of influence on child maltreatment. Consequently, there is a lack of consistency in structures and processes across programs. The variability in structures and processes within and across programs has contributed to the inconsistent findings related to the effectiveness of home visitation as a strategy to constrain child maltreatment. Identifying the underlying mechanisms that are facilitating or constraining program success or failure is essential for informing policy and practice. We propose the use of realist theory to identify the underlying mechanisms of home visitation programs. While realist theory has been used broadly in the social sciences, its uptake in nursing has been slow. Despite its limited use in nursing, realism's primary function, seeking to identify the underlying mechanisms in complex social programs, makes it suitable for investigating many complex phenomena that are of interest to nurse scientists. Here we discuss the theoretical foundations for home visitation programs, the recent evidence for program effectiveness, significant home visitation program components, and we propose a realist model for home visitation program evaluation that may aid in identifying how, for whom, and under what conditions home visitation programs work when these programs are implemented to address child maltreatment.

Nurse Cognition, Decision Support, and Barcode Medication Administration: A Conceptual Framework for Research, Practice, and Education.

This article synthesizes theoretical perspectives related to nurse cognition. We present a conceptual model that can be used by multiple stakeholders to study and contemplate how nurses use clinical decision support systems, and specifically, Barcode-Assisted Medication Administration, to make decisions during the delivery of care. Theoretical perspectives integrated into the model include dual process theory, the Cognitive Continuum Theory, human factors engineering, and the Recognition-Primed Decision model. The resulting framework illustrates the process of nurse cognition during Barcode-Assisted Medication Administration. Additionally, the model includes individual or human and environmental factors that may influence nurse cognition and decision making. It is important to consider the influence of individual, human, and environmental factors on the process of nurse cognition and decision making. Specifically, it is necessary to explore the impact of heuristics and biases on clinician decision making, particularly related to the development of alarm and alert fatigue. Aided by the proposed framework, stakeholders may begin to identify heuristics and cognitive biases that influence the decision of clinicians to accept or override a clinical decision support system alert and whether heuristics and biases are associated with inappropriate alert override.

Alert Types and Frequencies During Bar Code-Assisted Medication Administration: A Systematic Review.

BACKGROUND: Existing literature explores the effectiveness of bar code-assisted medication administration (BCMA) on the reduction of medication administration error as well as on nurse workarounds during BCMA. However, there is no review that comprehensively explores types and frequencies of alerts generated by nurses during BCMA. PURPOSE: The purpose was to describe alert generation type and frequency during BCMA. METHODS: A systematic review of the literature using PRISMA guidelines was conducted using CINAHL, PubMed, EMBASE, and Ovid Medline databases. RESULTS: After screening for inclusion and exclusion criteria, a total of 8 articles were identified and included in the review. Alert types included patient mismatch, wrong medication, and wrong dose, though other alert types were also reported. The frequency of alert generation varied across studies, from 0.18% to 42%, and not all alerts were clinically meaningful. CONCLUSIONS: This systematic review synthesized literature related to alert type and frequency during BCMA. However, further studies are needed to better describe alert generation patterns as well as factors that influence alert generation.

Resource scarcity drives lethal aggression among prehistoric hunter-gatherers in central California.

The origin of human violence and warfare is controversial, and some scholars contend that intergroup conflict was rare until the emergence of sedentary foraging and complex sociopolitical organization, whereas others assert that violence was common and of considerable antiquity among small-scale societies. Here we consider two alternative explanations for the evolution of human violence: (i) individuals resort to violence when benefits outweigh potential costs, which is likely in resource poor environments, or (ii) participation in violence increases when there is coercion from leaders in complex societies leading to group level benefits. To test these hypotheses, we evaluate the relative importance of resource scarcity vs. sociopolitical complexity by evaluating spatial variation in three macro datasets from central California: (i) an extensive bioarchaeological record dating from 1,530 to 230 cal BP recording rates of blunt and sharp force skeletal trauma on thousands of burials, (ii) quantitative scores of sociopolitical complexity recorded ethnographically, and (iii) mean net primary productivity (NPP) from a remotely sensed global dataset. Results reveal that sharp force trauma, the most common form of violence in the record, is better predicted by resource scarcity than relative sociopolitical complexity. Blunt force cranial trauma shows no correlation with NPP or political complexity and may reflect a different form of close contact violence. This study provides no support for the position that violence originated with the development of more complex hunter-gatherer adaptations in the fairly recent past. Instead, findings show that individuals are prone to violence in times and places of resource scarcity.

Variation in academic preparation and progression of nurses across the continuum of care.

BACKGROUND: Changing health care needs are driving new models of care that emphasize care coordination, health promotion, and disease management by registered nurses (RNs). A skill-mix favoring professional (baccalaureate or above) over technical (less than baccalaureate) education is promoted by national initiatives. PURPOSE: To examine the academic preparation and progression of general practice RNs in practice settings across the care continuum. METHOD: Secondary analyses of data from the Texas Board of Nurses RN Licensure databases in 2008 and 2014. FINDINGS: Overall the professional skill-mix for general practice RNs improved from 47.1% to 50.2%. Disparities were identified in home health (31.6%), long-term care (27.8%) and nonmetropolitan areas (31.7%). Role change was the strongest correlate of academic progression. DISCUSSION: Non-hospital and rural practice settings may be vulnerable to the effects of an undereducated RN workforce. More effective reimbursement policies and employer incentives are needed to drive academic progression and address disparities across practice settings.

Mitogenomics supports an unexpected taxonomic relationship for the extinct diving duck Chendytes lawi and definitively places the extinct Labrador Duck.

Chendytes lawi, an extinct flightless diving anseriform from coastal California, was traditionally classified as a sea duck, tribe Mergini, based on similarities in osteological characters. We recover and analyze mitochondrial genomes of C. lawi and five additional Mergini species, including the extinct Labrador Duck, Camptorhynchus labradorius. Despite its diving morphology, C. lawi is reconstructed as an ancient relictual lineage basal to the dabbling ducks (tribe Anatini), revealing an additional example of convergent evolution of characters related to feeding behavior among ducks. The Labrador Duck is sister to Steller's Eider which may provide insights into the evolution and ecology of this poorly known extinct species. Our results demonstrate that inclusion of full length mitogenomes, from taxonomically distributed ancient and modern sources can improve phylogeny reconstruction of groups previously assessed with shorter single-gene mitochondrial sequences.

Environmental productivity predicts migration, demographic, and linguistic patterns in prehistoric California.

Global patterns of ethnolinguistic diversity vary tremendously. Some regions show very little variation even across vast expanses, whereas others exhibit dense mosaics of different languages spoken alongside one another. Compared with the rest of Native North America, prehistoric California exemplified the latter. Decades of linguistic, genetic, and archaeological research have produced detailed accounts of the migrations that aggregated to build California's diverse ethnolinguistic mosaic, but there have been few have attempts to explain the process underpinning these migrations and why such a mosaic did not develop elsewhere. Here we show that environmental productivity predicts both the order of migration events and the population density recorded at contact. The earliest colonizers occupied the most suitable habitats along the coast, whereas subsequent Mid-Late Holocene migrants settled in more marginal habitats. Other Late Holocene patterns diverge from this trend, reflecting altered dynamics linked to food storage and increased sedentism. Through repeated migration events, incoming populations replaced resident populations occurring at lower densities in lower-productivity habitats, thereby resulting in the fragmentation of earlier groups and the development of one of the most diverse ethnolinguistic patterns in the Americas. Such a process may account for the distribution of ethnolinguistic diversity worldwide.

What Nurses Do During Time Scarcity-and Why.

Time scarcity is a common occurrence in the nurse work environment that stimulates a decision-making process, known as clinical prioritization or implicit rationing. In implicit rationing, nurses must decide what care they will complete and what they will leave unfinished. Five mechanisms that influence this process are supported in the literature. The effects of these influential mechanisms leave patients vulnerable to unmet educational, psychological, care coordination and discharge planning needs. Potential areas for intervention by nurse leaders include redesigning care delivery models to reduce time scarcity, adding balancing measures to performance monitoring systems to promote patient-centered care, and creating work cultures that support the values of nursing.

Measuring Unfinished Nursing Care: What to Consider When Choosing and Scoring Surveys.

Unfinished nursing care is common in the inpatient setting and is associated with negative patient outcomes. This indicator is being assessed with increasing frequency to determine the quality of nursing services. Measurement bias was identified in this comparison of unfinished care surveys. Potential sources of bias should be considered when selecting and scoring unfinished nursing care surveys for quality assessment.

Unfinished nursing care: An important performance measure for nursing care systems.

Performance measurement is a core administrative function and an essential component of organizational quality programs. The prevalence of performance measurement initiatives increased significantly after the release of the Institute of Medicine series on quality. Nursing performance measures are limited in their scope, resulting in an underrepresentation of process measures. Development of performance indicators that reflect how effectively organizational units actually transform nursing resources into nursing services should be a high priority. Unfinished nursing care is a nursing process performance measure that reflects the complexity of the nursing care environment and can be useful in comparing process performance across systems and organizations. Unfinished nursing care is congruent with many of the National Quality Forum requirements for endorsement and warrants further refinement as an important nurse-sensitive performance measure.

Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges

Nurses have a social responsibility to evaluate the effect of nursing practice on patient outcomes in the areas of health promotion; injury and illness prevention; and alleviation of suffering. Quality assessment initiatives are hindered by the paucity of available data related to nursing processes and patient outcomes across these three domains of practice. Direct care nurses are integral to self-regulation for the discipline as they are the best source of information about nursing practice and patient outcomes. Evidence supports the assumption that nurses do contribute to prevention of adverse events but there is insufficient evidence to explain how nurses contribute to these and/or other patient outcomes. The purposes of this article are to examine the imperatives, ideal conditions, history, and challenges related to effective outcome measurement in nursing. The article concludes with recommendations for action to move quality assessment forward, such as substantial investment to support adequate documentation of nursing practice and patient outcomes.

Dimensions of nurse work time: Progress in instrumentation.

Because the work of health care is embedded in time, understanding nursing time-allocation practices is essential for identifying nurse staffing and workflow patterns that optimize healthcare cost and quality outcomes. The interdependent nature of nursing care requires that nurses share time with other members of their work group. Shared time, also known as social or organizational time, requires careful negotiation of workflows within healthcare teams. Evaluation of negotiated workflows is contingent upon valid and reliable measures of sociological nursing time. In this study, we evaluated the psychometric properties of a newly adapted instrument for measuring sociological nursing time and describe the experience of sociological time among hospital-employed nurses. Using a cross-sectional survey design with a convenience sample of nurses (n = 359), we identified nine reliable components of sociological nursing time: insufficient time allocation; strict adherence to schedules; increased time awareness; value of quality over speed; fast and unpredictable pace changes; predictable job duties punctuated with unpredictable job demands; expectations for a fast work pace; inconsistent work-hour expectations across departments; and high expectations for punctuality.

A Descriptive Analysis of Implicit Rationing of Nursing Care: Frequency and Patterns in Texas.

The frequency and patterns of implicit rationing of nursing care in the United States are not known. The purpose of this study was to examine the phenomenon of implicit rationing among nurses in Texas. Implicit rationing was measured using a 31-item survey instrument adapted from the parent instrument originating in Switzerland. Some degree of rationing on at least one of the nursing care activities was reported by almost all of the respondents and most rationed multiple activities. Rationing preference patterns favor completion of activities directed to meet immediate physiological needs over other activities. If the relationships documented in other countries between implicit rationing and adverse patient outcomes are also present in the United States, then implicit rationing may serve as an important quality indicator.

Can real time location system technology (RTLS) provide useful estimates of time use by nursing personnel?

Accurate, precise, unbiased, reliable, and cost-effective estimates of nursing time use are needed to insure safe staffing levels. Direct observation of nurses is costly, and conventional surrogate measures have limitations. To test the potential of electronic capture of time and motion through real time location systems (RTLS), a pilot study was conducted to assess efficacy (method agreement) of RTLS time use; inter-rater reliability of RTLS time-use estimates; and associated costs. Method agreement was high (mean absolute difference = 28 seconds); inter-rater reliability was high (ICC = 0.81-0.95; mean absolute difference = 2 seconds); and costs for obtaining RTLS time-use estimates on a single nursing unit exceeded $25,000. Continued experimentation with RTLS to obtain time-use estimates for nursing staff is warranted.

Radiofrequency identification: exploiting an old technology for measuring nurse time and motion.

A national campaign is underway to increase the amount of time staff nurses spend at the bedside of hospitalized patients through redesign of the work environment. This kind of work redesign requires robust data depicting what nurses do and how they spend their time. Historically, these kinds of data have been difficult, costly, and time consuming to collect. Wireless capture of data on the movement of humans within the work environment (ie, time and motion) is now possible through radiofrequency identification technology. When small tracking devices the size of a quarter are affixed to their clothing, the movement of nurses throughout a patient care unit can be monitored. The duration and frequency of patient interaction are captured along with the duration of time spent in other locations of interest to include nurses' station, supply room, medication room, doctors' station, electronic documentation stations, family waiting rooms, and the hallway. Patterns of nurse movement and time allocation can be efficiently identified, and the effects of staffing practices, workflows, and unit layout evaluated. Integration of radiofrequency identification time and motion data with other databases enables nurse leaders to link nursing time to important cost and quality outcomes. Nurse leaders should explore the usefulness of radiofrequency identification technology in addressing data needs for nurse time and motion.

Rapid response teams and failure to rescue: one community's experience.

The rapid response team has been proposed as an effective strategy for reducing failure-to-rescue rates among adult inpatients; however, there is little research evidence to support the recommendation. This exploratory study used survey and administrative data to describe rapid response team characteristics and penetration among hospitals in a large metropolitan area while tracking corresponding failure-to-rescue rates among surgical inpatients over 5 years. The findings are promising and invite further investigation.