Multi-Site Study of Provider Self-Efficacy and Beliefs in Explaining Judgments About Need and Responsibility for Advance Care Planning.

BACKGROUND AND OBJECTIVES: We examined the impact of advance care planning (ACP) self-efficacy and beliefs in explaining skilled nursing facility (SNF) provider judgments about resident need and provider responsibility for initiating ACP conversations. RESEARCH DESIGN AND METHODS: This observational multi-site study of 348 registered nurses, licensed practical nurses, and social workers within 29 SNFs used an anonymous survey in which providers judged vignettes with assigned situational features of a typical SNF resident. Mixed modeling was used to analyze the vignette responses. RESULTS: Providers who had more negative beliefs about ACP were less likely to judge residents in need of ACP and less likely to feel responsible for ensuring ACP took place. Self-efficacy did not have a significant impact on judgments of need, but did significantly increase judgments of responsibility for ensuring ACP conversations. Providers with the highest levels of ACP self-efficacy were most likely to feel responsible for ensuring ACP conversations. In an exploratory analysis, these relationships remained the same whether responding to high or low risk residents (i.e., based on risk of hospitalization, type of diagnosis, functional status, and rate of declining health). DISCUSSION AND IMPLICATIONS: Both negative beliefs about ACP and self-efficacy in one's ability to conduct ACP discussions were associated with professional judgments regarding ACP. The findings illustrate the importance of addressing negative beliefs about ACP and increasing provider ACP self-efficacy through education and policies that empower nurses and social workers.

Pet-1 Controls Tetrahydrobiopterin Pathway and Slc22a3 Transporter Genes in Serotonin Neurons.

Coordinated serotonin (5-HT) synthesis and reuptake depends on coexpression of Tph2, Aadc (Ddc), and Sert (Slc6a4) in brain 5-HT neurons. However, other gene products play critical roles in brain 5-HT synthesis and transport. For example, 5-HT synthesis depends on coexpression of genes encoding the enzymatic machinery necessary for the production and regeneration of tetrahydrobiopterin (BH4). In addition, the organic cation transporter 3 (Oct3, Slc22a3) functions as a low affinity, high capacity 5-HT reuptake protein in 5-HT neurons. The regulatory strategies controlling BH4 and Oct3 gene expression in 5-HT neurons have not been investigated. Our previous studies showed that Pet-1 is a critical transcription factor in a regulatory program that controls coexpression of Tph2, Aadc, and Sert in 5-HT neurons. Here, we investigate whether a common regulatory program determines global 5-HT synthesis and reuptake through coordinate transcriptional control. We show with comparative microarray profiling of flow sorted YFP(+) Pet-1(-/-) and wild type 5-HT neurons that Pet-1 regulates BH4 pathway genes, Gch1, Gchfr, and Qdpr. Thus, Pet-1 coordinates expression of all rate-limiting enzymatic (Tph2, Gch1) and post-translational regulatory (Gchfr) steps that determine the level of mammalian brain 5-HT synthesis. Moreover, Pet-1 globally controls acquisition of 5-HT reuptake in dorsal raphe 5-HT neurons by coordinating expression of Slc6a4 and Slc22a3. In situ hybridizations revealed that virtually all 5-HT neurons in the dorsal raphe depend on Pet-1 for Slc22a3 expression; similar results were obtained for Htr1a. Therefore, few if any 5-HT neurons in the dorsal raphe are resistant to loss of Pet-1 for their full neuron-type identity.