Examining the Impact of a Nursing Course Redesign on Student Outcomes, Faculty Workload, and Costs.

ABSTRACT: This study examined the impact of a nursing course redesign from traditional face-to-face to a hybrid format on student outcomes, workload allocation, and associated costs. In this quasi-experimental study, baccalaureate students received either traditional (n = 47) or hybrid delivery (n = 46); each group had equal degree-type representation. Average exam scores were analyzed using an independent t-test, with no significant differences found between groups. Faculty workload decreased by one third, and there was a 16.6 percent reduction in overall costs to implement the course. Course redesign can be effective for reducing faculty workload and costs while achieving course outcomes.

Simulating a Community Mental Health Service During the COVID-19 Pandemic: Effects of Clinician-Clinician Encounters, Clinician-Patient-Family Encounters, Symptom-Triggered Protective Behaviour, and Household Clustering.

Objectives: Face-to-face healthcare, including psychiatric provision, must continue despite reduced interpersonal contact during the COVID-19 (SARS-CoV-2 coronavirus) pandemic. Community-based services might use domiciliary visits, consultations in healthcare settings, or remote consultations. Services might also alter direct contact between clinicians. We examined the effects of appointment types and clinician-clinician encounters upon infection rates. Design: Computer simulation. Methods: We modelled a COVID-19-like disease in a hypothetical community healthcare team, their patients, and patients' household contacts (family). In one condition, clinicians met patients and briefly met family (e.g., home visit or collateral history). In another, patients attended alone (e.g., clinic visit), segregated from each other. In another, face-to-face contact was eliminated (e.g., videoconferencing). We also varied clinician-clinician contact; baseline and ongoing "external" infection rates; whether overt symptoms reduced transmission risk behaviourally (e.g., via personal protective equipment, PPE); and household clustering. Results: Service organisation had minimal effects on whole-population infection under our assumptions but materially affected clinician infection. Appointment type and inter-clinician contact had greater effects at low external infection rates and without a behavioural symptom response. Clustering magnified the effect of appointment type. We discuss infection control and other factors affecting appointment choice and team organisation. Conclusions: Distancing between clinicians can have significant effects on team infection. Loss of clinicians to infection likely has an adverse impact on care, not modelled here. Appointments must account for clinical necessity as well as infection control. Interventions to reduce transmission risk can synergize, arguing for maximal distancing and behavioural measures (e.g., PPE) consistent with safe care.

Temporal Trends in Fall Rates with the Implementation of a Multifaceted Fall Prevention Program: Persistence Pays Off.

BACKGROUND: Most fall prevention programs are only modestly effective, and their sustainability is unknown. An academic medical center implemented a series of fall prevention interventions from 2001 to 2014. METHODS: The medical center's series of fall prevention interventions were as follows: reorganized the Falls Committee (2001), started flagging high-risk patients (2001), improved fall reporting (2002), increased scrutiny of falls (2005), instituted hourly nursing rounds (2006), reorganized leadership systems (2007), standardized fall prevention equipment (2008), adapted to a move to a new hospital building (2008), routinely investigated root causes (2009), mitigated fall risk during hourly nursing rounds (2009), educated patients about falls (2011), and taught nurses to think critically about risk (2012). To evaluate temporal trends in falls and injury falls, piecewise negative binomial regression with study unit-level random effects was used to analyze structured validated data sets available since 2003. RESULTS: From July 2003 through December 2014, the crude fall rate declined from 3.07 to 2.22 per 1,000 patient days, and injury falls declined from 0.77 to 0.65 per 1,000 patient days. Nonsignificant increases in falls occurred after nurses started rounding hourly and after the move to the new hospital. On the basis of regression models, significant declines occurred after nurses began to mitigate fall risk during hourly rounds (p = 0.009). CONCLUSION: Instituting incremental changes for more than a decade was associated with a meaningful (about 28%) and sustained decline in falls, although the rate of decline varied over time. Hospitals interested in reducing falls but concerned about competing clinical and financial priorities may find an incremental approach to be effective.

Waging the War on Clinical Grade Inflation: The Ongoing Quest.

This study examined the presence of grade inflation in clinical courses 9 years after implementing strategies to improve grading precision. A comparison of clinical grades for cohort I (1997-2002) with cohort II (2009-2016) showed statistically lower grades in 2 courses (Adult 1 and Maternity) for cohort II. Suggestions for changing the way clinical experiences are planned, executed, and evaluated are provided.

Clinical Effectiveness and Cost of a Hospital-Based Fall Prevention Intervention: The Importance of Time Nurses Spend on the Front Line of Implementation.

OBJECTIVE: The aim of this study is to evaluate the clinical effectiveness and incremental net cost of a fall prevention intervention that involved hourly rounding by RNs at 2 hospitals. BACKGROUND: Minimizing in-hospital falls is a priority, but little is known about the value of fall prevention interventions. METHODS: We used an uncontrolled before-after design to evaluate changes in fall rates and time use by RNs. Using decision-analytical models, we estimated incremental net costs per hospital per year. RESULTS: Falls declined at 1 hospital (incidence rate ratio [IRR], 0.47; 95% confidence interval [CI], 0.26-0.87; P = .016), but not the other (IRR, 0.83; 95% CI, 0.59-1.17; P = .28). Cost analyses projected a 67.9% to 72.2% probability of net savings at both hospitals due to unexpected declines in the time that RNs spent in fall-related activities. CONCLUSIONS: Incorporating fall prevention into hourly rounds might improve value. Time that RNs invest in implementing quality improvement interventions can equate to sizable opportunity costs or savings.

Is Spending More Time Associated With Less Missed Care?: A Comparison of Time Use and Missed Care Across 15 Nursing Units at 2 Hospitals.

OBJECTIVE: The aim of this study is to examine the relationship between nursing time use and perceptions of missed care. BACKGROUND: Recent literature has highlighted the problem of missed nursing care, but little is known about how nurses' time use patterns are associated with reports of missed care. METHODS: In 15 nursing units at 2 hospitals, we assessed registered nurse (RN) perceptions of missed care, observed time use by RNs, and examined the relationship between time spent and degree of missed care at the nursing unit level. RESULTS: Patterns of time use were similar across hospitals, with 25% of time spent on documentation. For 6 different categories of nursing tasks, no association was detected between time use, including time spent on documentation, and the degree of missed care at the nursing unit level. CONCLUSIONS: Nursing time use cannot fully explain variation in missed care across nursing units. Further work is needed to account for patterns of missed care.

HESI admission assessment (A(2)) examination scores, program progression, and NCLEX-RN success in baccalaureate nursing: an exploratory study of dependable academic indicators of success.

In an effort to meet the demand for well-educated, high-quality nurses, schools of nursing seek to admit those candidates most likely to have both timely progression and first-time success on the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Finding the right combination of academic indicators, which are most predictive of success, continues to be an ongoing challenge for entry-level baccalaureate nursing programs across the United States. This pilot study explored the relationship of a standardized admission examination, the Health Education Systems, Inc. (HESI) Admission Assessment (A(2)) Examination to preadmission grade point average (GPA), science GPA, and nursing GPA using a retrospective descriptive design. In addition, the predictive ability of the A(2) Examination, preadmission GPA, and science GPA related to timely progression and NCLEX-RN success were explored. In a sample of 89 students, no relationship was found between the A(2) Examination and preadmission GPA or science GPA. The A(2) Examination was correlated with nursing GPA and NCLEX-RN success but not with timely progression. Further studies are needed to explore the utility and predictive ability of standardized examinations such as the A(2) Examination and the contribution of such examinations to evidence-based admission decision making.

Identification of key residues that confer Rhodobacter sphaeroides LPS activity at horse TLR4/MD-2.

The molecular determinants underpinning how hexaacylated lipid A and tetraacylated precursor lipid IVa activate Toll-like receptor 4 (TLR4) are well understood, but how activation is induced by other lipid A species is less clear. Species specificity studies have clarified how TLR4/MD-2 recognises different lipid A structures, for example tetraacylated lipid IVa requires direct electrostatic interactions for agonism. In this study, we examine how pentaacylated lipopolysaccharide from Rhodobacter sphaeroides (RSLPS) antagonises human TLR4/MD-2 and activates the horse receptor complex using a computational approach and cross-species mutagenesis. At a functional level, we show that RSLPS is a partial agonist at horse TLR4/MD-2 with greater efficacy than lipid IVa. These data suggest the importance of the additional acyl chain in RSLPS signalling. Based on docking analysis, we propose a model for positioning of the RSLPS lipid A moiety (RSLA) within the MD-2 cavity at the TLR4 dimer interface, which allows activity at the horse receptor complex. As for lipid IVa, RSLPS agonism requires species-specific contacts with MD-2 and TLR4, but the R2 chain of RSLA protrudes from the MD-2 pocket to contact the TLR4 dimer in the vicinity of proline 442. Our model explains why RSLPS is only partially dependent on horse TLR4 residue R385, unlike lipid IVa. Mutagenesis of proline 442 into a serine residue, as found in human TLR4, uncovers the importance of this site in RSLPS signalling; horse TLR4 R385G/P442S double mutation completely abolishes RSLPS activity without its counterpart, human TLR4 G384R/S441P, being able to restore it. Our data highlight the importance of subtle changes in ligand positioning, and suggest that TLR4 and MD-2 residues that may not participate directly in ligand binding can determine the signalling outcome of a given ligand. This indicates a cooperative binding mechanism within the receptor complex, which is becoming increasingly important in TLR signalling.

Castration of horses under total intravenous anaesthesia: analgesic effects of lidocaine.

OBJECTIVE: To evaluate the effects of local anaesthesia with lidocaine for castration of horses under intravenous anaesthesia. STUDY DESIGN: Prospective, randomized, blinded clinical trial. ANIMALS: Fifteen equidae, scheduled to undergo castration under total intravenous anaesthesia, were randomly distributed in two groups. One group received lidocaine injections (group L: two ponies, four horses, two donkeys) and the other received saline (group S: two ponies, three horses, two donkeys). METHODS: Behaviour, heart rate (HR) and respiratory rate (f(R)) were evaluated prior to anaesthesia. Body mass was measured using an electronic scale and testicular volumes were estimated. The animals were anaesthetized with acepromazine intramuscularly and romifidine intravenously followed 10 minutes later by ketamine. Following romifidine administration lidocaine or saline was administered subcutaneously along the incision line and by intratesticular and intrafunicular injection. Based on clinical observations (movement, f(R), and cranial nerve reflexes) incremental intravenous doses of ketamine and romifidine were administered. HR, f(R), oscillometric mean arterial blood pressure (MAP), duration of surgery, movement and additional doses were recorded. Surgical conditions were assessed using a visual analogue scale (VAS) and a simple descriptive scale (SDS). Recovery was assessed by two assistants, unaware of treatment, acting separately using a VAS and a SDS. Group means were compared using Mann-Whitney and Wilcoxon tests and the Kruskal-Wallis signed rank test for matched pairs used to compare groups at different points (p < 0.05). RESULTS: The number (median, range) of incremental doses (4 [1-5] compared to 1.5 [1-4]) and movements (1 [1-5] compared to 0 [0-1]) were higher (p = 0.01 for both) in the control group than in the lidocaine group. Groups were similar for other recorded variables. CONCLUSIONS AND CLINICAL RELEVANCE: These results show the effectiveness of lidocaine used as a local anaesthetic adjunct to intravenous anaesthesia in horses undergoing castration.

Developing a practical evaluation tool for preceptor use.

After years of dissatisfaction with existing instruments, a tool for preceptors to evaluate an undergraduate student's clinical performance was developed, with preceptors' input in its construction. A 2-year pilot evaluation revealed notable problems including excessively high preceptor ratings and significant disparities between faculty and preceptor ratings. Further revisions were made, reducing indicators to those which the preceptors can actually evaluate on an everyday basis and developing a rubric. Additional recommendations to bolster the quality of ratings are improving orientation and guidance of preceptors and modifying procedures for giving feedback.

California Critical Thinking Disposition Inventory: further factor analytic examination.

The stability of the factor structure of the California Critical Thinking Disposition Inventory was re-examined using a convenience sample of 800 undergraduate students from nursing (n=520 first bachelors' and n=185 second bachelors' students) and biology (n=95) enrolled in introductory courses in their majors at a 4-yr. mid-Atlantic public university. Ages ranged from 17 to 54 years (M = 23.0, SD = 5.9), with 92 men and 707 women (1 missing). 685 participants identified themselves as Euro-American, 65 as African American, 9 as Hispanic, 26 as Asian, and 11 as "Other" (4 missing). The inventory developed by Facione in 1994 is a 75-item, forced-choice, adjective checklist, yielding seven subscores and a total score assessing testees' disposition toward critical thinking. A principal components factor analysis did not replicate the original factor structure of seven factors but supported the stability of a four-factor structure which had emerged in previous work by Walsh and Hardy and by Kakai. When the 75 original items were reduced to 25, the explained variance for the inventory improved from 27% to 44.95%. Thus, further investigation and continued refinement is warranted.

Immunomodulatory effects of Pseudomonas aeruginosa quorum sensing small molecule probes on mammalian macrophages.

Pseudomonas aeruginosa produces the quorum sensing signalling molecule N-(3-oxododecanoyl)-L-homoserine lactone (OdDHL). This natural product not only coordinates production of virulence factors by the bacterium, but also has immunomodulatory effects on the host organism. Immunomodulatory small molecules are valuable for immunology research and are potential therapeutics for autoimmune diseases such as rheumatoid arthritis, and immunosuppressive drugs following organ transplants. We describe the total synthesis of OdDHL using solid-supported reagents and scavengers, which has the potential to be used for automated analogue synthesis. OdDHL and four analogues were tested for their ability to activate or inhibit release of the pro-inflammatory mediators tumour necrosis factor alpha (TNFalpha) and nitric oxide (NO) from equine or murine macrophages (immune cells). Two of the analogues showed substantial immunomodulatory activity with these macrophages. One analogue showed differing species selectivity, being a potent antagonist in mouse cells, but a partial agonist in horse-derived macrophages. These compounds have the therapeutic potential to be used for protecting animals from bacterial septic shock.

Measuring critical thinking: one step forward, one step back.

When critical thinking was identified as an explicit program outcome by the National League for Nursing in 1991, nursing programs were thrust into frenzied activity defining critical thinking and selecting instruments to evaluate it. This drove research on the measurement of critical thinking among nursing programs and the concomitant search for reliable and valid methodologies to systematically assess changes in critical thinking in their students. Although the ultimate goal of this process was curricular improvement, nearly 15 years later, faculty struggle to make sense of the data they have.

Critical thinking: back to square two.

Tracking the development of critical thinking in students presents challenges for nursing programs. After 8 years of measuring critical thinking with mixed results, faculty at one school analyzed current beliefs and practices with a focus on the type of thinking that is reinforced in both classroom and clinical settings and the effects of classroom technology on critical thinking. Recommendations for the conceptualization of critical thinking and its measurement, as well as teaching strategies to emphasize principles over "coverage," are proposed.

Measuring critical thinking in graduate education: what do we know?

Accrediting and specialty organizations agree that a master's education expands critical thinking skills gained during undergraduate study, yet a review of literature revealed a lack of research measuring critical thinking of students enrolled in postbaccalaureate education in nursing and other fields. Of 35 studies retrieved, 17 were conducted on undergraduate nursing students, with the remainder spread across practicing RNs, and master's level students in physical therapy, business, medicine, and nursing. A critique of this research and recommendations for future study are presented.

Evaluating student performance in undergraduate preceptorships.

This article explores the challenges in evaluating student performance in preceptorships based on data collected during academic years 1999-2002, which revealed an unusually large number of high grades and relatively few average grades. Multiple perspectives are explored, including preceptor issues of selection, orientation, recognition, role conflict, and experience with giving grades; faculty issues of role confusion and unclear expectations for student performance; and environmental issues of lack of control of the learning environment and differences in the values of education and workplace. Solutions are proposed, including an orientation for preceptors and faculty, ongoing faculty mentoring of preceptors, official preceptor recognition, clear articulation of expectations for student performance and faculty site visits, and creation of grading rubrics for various aspects of the course to be used by preceptors, faculty, and students.

Clinical grades: upward bound.

This study examined the relationship of grades earned in paired theory and clinical courses. Data collected during academic years 1997 to 2002 confirmed that grade inflation exists in clinical nursing courses. Problems involved in awarding grades for clinical performance are discussed (e.g., standards of clinical performance, methods used in evaluation of clinical performance, the impossibility of faculty omnipresence, the influence of student effort in grading, the effect of recency, the challenges of keeping good anecdotal records). Solutions to grading problems are proposed, including dividing up performance into agreed-on elements, measurement of these elements on a grading scale that allows for more differentiation of quality in evaluating clinical performance, assigning grades from the beginning of a clinical course, emphasizing all three domains of clinical practice, and evaluating student performance in both laboratory and, clinical settings.

A clinical evaluation of the 'mini parallel Lack' breathing system in cats and comparison with a modified Ayre's T-piece.

OBJECTIVE: To evaluate the suitability of a 'mini parallel Lack' (MPL) breathing system for use in spontaneously breathing cats and to compare the fresh gas flow requirement with that of a modified Ayre's T-piece (MATP). ANIMALS: Twenty client-owned cats, ASA I and II, presented for elective procedures requiring anaesthesia. MATERIALS AND METHODS: Pre-anaesthetic medication and induction of anaesthesia were carried out using several techniques commonly used in our teaching hospital. Anaesthesia was maintained with halothane or isoflurane vaporized in either oxygen or with a mixture of oxygen and nitrous oxide. Both breathing systems were evaluated in each cat, with the order of use randomized. Initial fresh gas flows were 300 mL kg(-1) minute(-1) for the MPL and 500 mL kg(- 1) minute(-1) for the MATP. After a 20-minute stabilization period, fresh gas flow was reduced by 200 mL minute(-1) every 5 minutes until re-breathing--defined as an increase in the inspired partial pressure of carbon dioxide to 0.3 kPa (2 mm Hg)--was detected. The fresh gas flow was then increased in 100 mL minute(-1) increments until re-breathing was no longer detectable, and this value was recorded as the minimum fresh gas flow requirement for the breathing system in use. The procedure was then repeated for the second breathing system. Minimum fresh gas flow requirements were compared using a paired Students t-test. Cardiopulmonary variables were compared using anova. Valve opening pressure was measured in the MPL using a manometer. RESULTS: The mean (+/-SD) fresh gas flow that prevented re-breathing with the MPL (510 +/- 170 mL minute(-1); equivalent to 142 +/- 47 mL kg(-1) minute(-1)) was significantly lower than that required for the MATP (1430 +/- 560 mL minute(-1); equivalent to 397 +/-155 mL kg(-1) minute(-1)). There were no significant differences in cardiopulmonary variables attributable to the use of the two breathing systems. The MPL valve opening pressure was 1.1 cm H2O. CONCLUSIONS: The MPL breathing system used lower gas flows than the MATP without affecting cardiovascular or respiratory function. Clinical relevance In spontaneously breathing cats, the MPL offers the advantages of a reduction in cost and atmospheric pollution because less volatile agent is vaporized.