A nurse practitioner model of practice in the neonatal intensive care unit.

PURPOSE: The purpose of this study was to describe the practice of the nurse practitioner (NP) in the neonatal intensive care unit (NICU) in an attempt to define an advanced practice nursing model that is unique to NP practice in the NICU. DESIGN: This qualitative research used an ethnographic case study design to answer the research question: 'What is the practice model of nurse practitioners working in the NICU?' METHODS: Seven nurse practitioners working in five level II/III NICUs in Massachusetts and Rhode Island were interviewed and observed in practice. Audiotaped interviews using open-ended questions and field notes from participant observations were analyzed for patterns of behavior. RESULTS: These nurse practitioners practiced within a model of advanced practice nursing that emphasized health, holism, and caring within the highly technological and medical NICU environment. CLINICAL IMPLICATIONS: A model of NP practice in the NICU is emerging and needs further development and testing. Nurse educators and administrators must find ways to support the nursing model in the advanced practice nursing role in the NICU. Nurse practitioners need to be more active in promoting a clearer understanding of their practice and contributions to the NICU care delivery team.

Low-dose daily subcutaneous interleukin-2 in combination with highly active antiretroviral therapy in HIV+ patients: a randomized controlled trial.

PURPOSE: Previous studies with intermittent interleukin-2 (IL-2) therapy using intermediate and high levels of IL-2 have demonstrated significant increases in the CD4 + T cell count in HIV-infected patients. Intermittent regimens are amenable to outpatient use, but severe adverse events are frequently experienced with intermediate- and high-dose levels of IL-2. Therefore in this study, the effect of daily, subcutaneous low-dose IL-2 therapy on safety and immunological endpoints was investigated to determine whether immunological benefit could be achieved without toxicity in HIV-infected patients also receiving highly active antiretroviral therapy (HAART). METHOD: A total of 115 patients were enrolled in the trial. Fifty-six asymptomatic HIV-infected patients who had CD4 + T cell counts less than 300 cells/microL at screening and a stable HIV viral load received low-dose IL-2 (1.2 million IU [MIU]/m 2 beginning dose) once daily in conjunction with HAART (IL-2 group). Fifty-nine patients received HAART alone (control group). RESULTS: A dramatic effect of IL-2 on the natural killer (NK) cell population was observed with mean increases of 156 cells/microL in the IL-2 group compared to 19.93 cells/microL in the control group (p <.001). Additionally, IL-2-treated patients experienced a statistically significant increase in the mean percentage of CD4 + T cells (3.52% increase) when compared to control patients (1.33% increase) (p <.001). The expanded CD4 + T cell population was primarily of the naive phenotype, with mean increases of 4.53% for the IL-2 group and 0.31% for the control group (p <.001 for between-group difference). In addition, a higher proportion of IL-2-treated patients (67%) compared to control patients (33%) achieved increases of greater than 50% in the CD4+ T cell count (p =.08). Adverse events of grade 3 or grade 4 toxicity were infrequent in the current study and were substantially lower by comparison to those in studies of intermittent dose IL-2 therapy. Also, negligible changes in the HIV viral load from baseline to final measurement were observed in both groups. A trend toward a reduced number of modifications of antiretroviral therapy was apparent in the IL-2 group when compared to control patients. CONCLUSION: Daily, low-dose subcutaneous IL-2 therapy in conjunction with HAART is safe and well tolerated and is effective in expanding lymphocyte cell types including NK cells and naive T cells in individuals who have <300 CD4+ T cells.

Responsibilities, roles & staffing patterns of nurse practitioners in the neonatal intensive care unit.

PURPOSE: To describe the unique contribution of the NP in caring for critically ill infants through the study of NP responsibilities, roles, staffing patterns, and patient profiles. DESIGN: This prospective descriptive study was conducted in conjunction with a regional multi-site outcomes study. METHODS: Data were collected at five regional level II/III NICUs in Massachusetts and Rhode Island. Twenty-two NPs were surveyed. Existing data on outcomes of 2,146 very low birth weight infants were used to describe patient profiles. NP care was defined as assignment to an NP at admission. Illness severity was measured using the Score of Neonatal Acute Physiology (SNAP). RESULTS: NP roles included all levels of NICU care as well as antepartal consultation, delivery room management, transport, and outpatient follow-up. NPs were equally involved with patients of all degrees of complexity and birthweights. Patient assignments were most often made by a rotational system with the resident/fellow or by complexity of infant with the NP in some NICUs caring for sicker smaller babies. CLINICAL IMPLICATIONS: This study documents a blended model of NP MD care in the NICU with each provider bringing unique strengths to the team. Nurse practitioners working in the NICU provide an invaluable contribution in terms of parent support and teaching, post NICU follow-up care, and professional education and research. The NP role in the NICU should not be viewed as a substitution for resident physicians.

The role of the neonatal nurse practitioner in post NICU follow-up.

This descriptive correlational study explored the role of neonatal nurse practitioners (NNPs) in postneonatal intensive care unit follow-up. A random sample of 505 NNPs completed a researcher-developed instrument pretested for reliability and validity. There was overwhelming agreement (96%) that a role exists for NNPs in follow-up. In total, 52% felt qualified to provide follow-up and 22% were currently in the role. NNPs with previous primary care experience (P = 0.010) were more involved in follow-up. NNPs with additional certification (P = 0.016) or previous primary care experience (P = 0.003) felt more qualified to provide follow-up care. Facilitators and barriers to the role were identified by NNPs providing follow-up care.

Exploring the lived-experience of childhood cancer survivors.

The purpose of this qualitative phenomenological study was to explore the lived-experience of childhood cancer survivors with regard to their patterns of interaction with family and the environment using Newman's theory of Health as Expanding Consciousness, which proposes that experiencing a devastating event promotes an expanded consciousness. The sample consisted of five young adults, ages 23 to 26 years, who had experienced childhood cancer and now are considered to be cured of their initial cancer. A hermeneutic dialectic approach was used, with each subject being asked to respond to one open-ended question, "What are the most meaningful events in your life?" The interviews were analyzed for evidence of expanded consciousness, changing relatedness, and other universal themes. Individual patterns emerged and themes were identified that supported Newman's theory, such as optimism and hope, stronger bonds to family and friends, increased capacity for empathy, a desire to help others, and deeper feelings for the value of life. The intensely personal and professional relationship that develops between pediatric oncology nurses and their patients can only be strengthened by the knowledge that these patients generally grew up to be caring and empathetic individuals, perhaps as a result of the nurses' loving care for them. This research also provided support for Newman's theory as a sound paradigm for nursing practice.

Quantitative and neurogenic analysis of the total population and subpopulations of neurons defined by axon projection in the superficial dorsal horn of the rat lumbar spinal cord.

The total neuron population of the superficial dorsal horn (SDH), i.e., laminae I and II, was quantitated in Nissl preparations of spinal segment L1 in the rat. Subpopulations of the SDH, defined by axon projection, were quantitated following strategic intraspinal injections of dual retrograde tracers (Fluoro-Gold and true blue). These methods were used in conjunction with [3H]thymidine (delivered in utero) autoradiography for neurogenic pattern analysis. Following stereological correction, each dorsal horn in spinal segment L1 contained 11 neurons in lamina I and 42.6 neurons in lamina II per 10-microm transverse section. Neurons with long projections, i.e., neurons with projections rostral to spinal segment T5, were only slightly more numerous in lamina I than in lamina II. These neurons made up 34% of the total neuron population in lamina I and 7.0% in lamina II. Most of these neurons did not demonstrate descending connections, and many (presumed supraspinal projection neurons) did not demonstrate short, ascending, intersegmental connections. Neurons with short propriospinal projections, i.e., neurons with connections caudal to spinal segment T5, made up approximately half of the total neuron population in both lamina I and lamina II: 55% and 52%, respectively. Of these, 79% had both short ascending and descending projections; the remaining 21% had only descending projections. Neurons that were not labeled with retrograde tracers (presumed local circuit cells) represented 11% of the neurons in lamina I and 41% in lamina II. Neurogenesis in the SDH proceeded along an axon-length gradient, whereby neurons with the longest axons completed neurogenesis first, and those with the shortest completed neurogenesis last. The generation of both propriospinal and supraspinal projection neurons began on embryonic day 13 (E13). Nearly equal numbers of neurons in this group were generated in laminae I and II through E14. On E15, neuron production slowed in lamina I and accelerated in lamina II as local circuit neurons and the remaining propriospinal neurons were generated. Neuron production ceased simultaneously in both lamina I and lamina II on E16.

Quantitative and neurogenic analysis of neurons with supraspinal projections in the superficial dorsal horn of the rat lumbar spinal cord.

Dual retrograde axonal tracers, Fluoro-Gold (FG) and true blue (TB), were used in conjunction with [3H]thymidine autoradiography to determine the number and neurogenic pattern of neurons with supraspinal projections in the superficial dorsal horn (SDH), i.e., laminae I and II, in spinal segment L1 of the rat. FG was injected into rostral brain centers (dorsal thalamus and midbrain), and TB was injected into the caudal brainstem (medulla) in young adult rats previously administered [3H]thymidine in utero. Following stereological correction, each dorsal horn had an average of 1.22 neurons in lamina I and 0.24 neurons in lamina II that had supraspinal projections per 10-microm transverse section. In the SDH, 52% of the neurons with supraspinal projections were found to project to rostral brain centers alone, 3.0% only to the caudal brainstem, and 45% to both areas. There was no significant difference in the percentage distribution of each of the three groups of neurons between lamina I and lamina II. Cell counts in the present study, in conjunction with previous observations in the literature, suggest that the majority of supraspinal projection neurons in the SDH fall into two groups: 1) spinomesencephalic neurons with collaterals to the medulla and 2) spinothalamic neurons with collaterals to the midbrain. The neurogenesis of supraspinal projection neurons in the SDH proceeded along an axon-length gradient, whereby neurons with the longest axons, those with projections to rostral brain centers, completed neurogenesis prior to neurons with shorter axons, those with projections only to the caudal brainstem. The generation of all SDH neurons with supraspinal projections was completed on embryonic day 14 (E14), 2 days prior to the completion of neurogenesis for SDH neurons with intraspinal projections.

Role of self-efficacy in birth choice.

The incidence of vaginal birth after cesarean section is relatively low, although the procedure is of minimal risk to the mother and fetus. The article reports a pilot study designed to investigate whether a relationship exists between the concept of self-efficacy and delivery choice. The Childbirth Self-Efficacy Inventory, a self-administered questionnaire, was completed by 74 pregnant women. The study found that women choosing elective repeat cesarean delivery had lower self-efficacy scores on the instrument. The results suggest the need for further research using assessment of preoutcome, postoutcome, and self-efficacy expectancy scores with specifically designed classes for women who have had a previous cesarean birth.

Neonatal nurse practitioner role satisfaction.

The article reports a descriptive study utilizing a triangulated approach to explore the role satisfaction of a nationwide random sample of 315 neonatal nurse practitioners (NNPs). Role satisfaction was found to be high, and practice philosophy tended toward a medical orientation. Those NNPs who were master's prepared and who reported to and were evaluated and paid by departments of nursing were more likely to have a nursing practice philosophy. Intrinisic factors related to satisfaction included autonomy, patient management, relationships with colleagues and families, role diversity, and a sense of accomplishment. Implications for administrators and NNPs are discussed.

Neonatal nurse practitioners: identity as advanced practice nurses.

OBJECTIVE: To define how neonatal nurse practitioners (NNPs) perceive their identity as advanced practice nurses. DESIGN: Non-experimental descriptive and correlational survey. SETTING: Nationwide random sample drawn from NNPs certified by the National Certification Corporation. PARTICIPANTS: Two hundred fifty-eight neonatal nurse practitioners practicing in neonatal intensive-care units across the United States. MAIN OUTCOME MEASURES: Neonatal Nurse Practitioners indicated on a visual analogue scale at which point their philosophy of practice fell on a continuum from nursing to medicine and specified on a 5-point bipolar Likert scale how various role socialization factors influenced their identity. RESULTS: The NNPs predominantly were certificate-prepared and aligned themselves with a medical philosophy. Those NNPs who were master's-prepared (p < .01), precepted by another NNP (p < .05), espoused a philosophy of nursing (p < .001), belonged to a professional nursing organization (p < .05), and had an NNP role model (p < .001) were more likely to have a strong nursing identity (95% confidence interval). CONCLUSIONS: The issues of role differentiation, socialization, and identity of advanced practice nurses in tertiary care need further exploration. These data support the American Nurses' Association mandate of graduate nursing education for advanced nurse practitioners.

Creating a successful environment for neonatal nurse practitioners.

Factors that contribute to the neonatal nurse practitioner (NNP) practice environment have emerged from research grounded in the results of a nonexperimental, descriptive, and correlational study that described the role and nursing identity of 258 NNPs. These factors may be used as prescriptions for developing successful NNP environments or to strengthen a current practice. Nursing management has a responsibility to identify factors that enhance nursing identity of NNPs and to plan strategies to operationalize those factors to provide an optimal environment in which NNPs can practice to their fullest potential. Implications are raised for nursing administration and education to address the issues of role differentiation, socialization, and identity of advanced practice nurses in tertiary care.

Health-illness beliefs and practices of Haitians with HIV disease living in Boston.

The authors of this qualitative study explored the health-illness beliefs and practices of Haitians with HIV disease. The authors obtained a purposive sample of five Haitian men and four Haitian women with symptomatic HIV disease or AIDS living in Boston. Five themes were identified through content analysis of interviews and medical record review: (a) incorporation of traditional health-illness beliefs into beliefs about HIV disease; (b) A perceived need to hide HIV disease to avoid rejection, humiliation, and isolation; (c) use of spirituality to help cope with HIV disease; (d) history of limited contact with doctors prior to diagnosis of HIV disease; and (e) use of traditional healing practices for HIV disease. The findings have implications for improving cross-cultural communication between Haitians with HIV disease and their healthcare providers.

Neurogenesis of spinothalamic and spinocerebellar tract neurons in the lumbar spinal cord of the rat.

The temporal and spatial neurogenic patterns of spinothalamic and spinocerebellar neurons were determined in spinal cord segment L1 of the rat. Neurogenic patterns were demonstrated with [3H]thymidine administered to fetal rats during the period when neurons with supraspinal projections are known to be generated, i.e. on one of embryonic (E) days E13, E14, or E15. The animals were allowed to survive 50 to 100 days postpartum, then neurons with spinothalamic and spinocerebellar projections were retrogradely filled with fluorescent axonal tracers, Fluoro-Gold or True blue, which were pressure injected into the dorsal thalamus and cerebellum in various combinations in the same and in separate animals. Neurons labeled with each retrograde tracer and [3H]thymidine and neurons labeled with retrograde tracers alone were counted in spinal cord segment L1 in each of the animals. Spinothalamic and spinocerebellar neurons were found to be separate and distinct populations. Statistical analysis of the data showed that spinothalamic and spinocerebellar neurons also have distinctly different patterns of neurogenesis which suggest early determination in each cell line. The temporal neurogenic pattern followed a projection-distance gradient, such that spinothalamic neurons, which have longer axons than spinocerebellar neurons, completed neurogenesis prior to spinocerebellar neurons in each region of the spinal gray.

Transitory noradrenergic and peptidergic nerves in the cat kidney.

Indirect immunohistochemical methods were used to visualize nerves immunoreactive for tyrosine hydroxylase (TH), dopamine beta hydroxylase (DBH), neuropeptide Y, (NPY) and calcitonin gene-related peptide (CGRP) in sections of the kidneys of cats of different ages. Nerve terminals immunoreactive for TH, DBH and NPY innervated interlobar veins and the renal arterial tree including medullary vascular bundles of cats of each age studied. Most nerve terminals immunoreactive for CGRP innervated interlobar arteries. In kidneys of cats 2 to 10 weeks old, TH- and DBH-immunoreactive axons formed elaborate plexuses that were distributed throughout much of the outer two thirds of the inner medulla. Inner medullary NPY-immunoreactive nerve terminals formed sparse plexuses by comparison, thus suggesting a large population of TH-immunoreactive nerve terminals not immunoreactive for NPY. Plexuses immunoreactive for CGRP also innervated the inner medullae of young cats. Some inner medullary axons appeared degenerate in 8 and 10 week old cats, and no inner medullary nerve terminal plexuses were visualized in 12 week old or adult cats. Cell death or paring of axons resulting from mechanisms intrinsic to the neuronal population or from a change in trophic factors secreted or expressed by cells in the medulla may effect the loss of inner medullary nerve terminals in the kidneys of young cats.

Spinal neurogenesis and axon projection: a correlative study in the rat.

The purpose of the present study was to determine the relationship between the duration of a spinal neuron's neurogenic period and the length of its axon or level of projection. Spinal segment L1 was chosen for examination and neurons were divided into four projection groups: 1) supraspinal projection (SSp), 2) long ascending propriospinal (LAPr), 3) short ascending propriospinal (SAPr), and 4) descending propriospinal (DPr). To determine the duration of the neurogenic period for each group, 3H-thymidine was administered to fetal rats during the proliferative period for spinal neuroblasts on one of embryonic (E) days E13 through E16. Between 50 and 100 days after birth neurons in each group were labeled with the retrograde fluorescent tracer Fluoro-Gold. To demonstrate nerve cells with SSp projections, spinal cords were hemisected at spinal segment C3 in one group of animals and Fluoro-Gold was applied to the sectioned surface of the cord. Three additional sets of animals were used to label nerve cells with LAPr, SAPr, and DPr projections by injecting Fluoro-Gold into the gray matter at spinal segments C6, T12, and L5, respectively. Neurons labeled with both Fluoro-Gold and 3H-thymidine and neurons labeled with Fluoro-Gold alone in each animal in each group were counted and the data statistically analyzed. Results showed that within each spinal lamina neurons with different projections were generated, i.e., completed cell division, at significantly different rates. Neurons with the longest axons, those with SSP projections, were generated first. These were followed by those with LAPr projections, and finally those with SAPr and DPr projections. In most laminate there was no significant difference between the neurogenic periods of rostrally projecting short propriospinal (SAPr) neurons versus caudally projecting short propriospinal (DPr) neurons. It was concluded that the duration of the neurogenic period for a given group of neurons within each spinal lamina is inversely related to the distance between the nerve cell and its projection site regardless of the direction of its projection.