Developing interprofessional collaborative practice competencies in rural primary health care teams.

BACKGROUND: Leaders from a university, Area Health Education Center, and primary care centers (PCCs) collaborated to integrate Interprofessional Collaborative Practice (IPCP) in PCCs. PURPOSE: Describe the facilitators and barriers of IPCP implementation in rural clinics and the impact on decision-making and safety culture. METHODS: The implementation team used engagement strategies to support the development of IPCP. PCC team participants completed surveys measuring collaboration and satisfaction with care decisions and safety culture. Qualitative data were analyzed to describe facilitators and barriers to IPCP. FINDINGS: Significant improvement (p < .035) in the Global Amount of Collaboration made over time. Barriers to IPCP included high turnover, hierarchical culture, lack of role clarity, competing time demands, limited readiness for change, and physical space limitations. Facilitators included structured huddles, alignment of IPCP with organizational goals, and academic-practice partnership. DISCUSSION: Partnering with academic-practice partnerships may facilitate collaboration and team learning as PCCs incorporate IPCP into practice.

Coaching Strategies Used to Support Interprofessional Teams in 3 Primary Care Centers.

PURPOSE/AIMS: Clinical nurse specialists and other advanced practice registered nurses use healthcare team coaching to foster interprofessional practice and enhance healthcare quality. Although coaching has been shown to support positive changes in healthcare, little is known about how coaching strategies are used in practice. The purpose of this study was to describe the strategies used by an experienced healthcare team coach tasked with advancing interprofessional care and teamwork in primary care clinics. METHODS: This qualitative description study was part of a larger project that included an objective to increase interprofessional practice in 3 primary care clinics in the midwestern United States. Data drawn from 35 audio-recorded and transcribed coaching telephone calls were analyzed using content analysis. RESULTS: Twelve coaching strategies were identified and divided into the following groups: (a) enhancing team development, (b) affirming the work of the team, (c) facilitating progress, (d) providing resources, and (e) connecting work to theoretical frameworks. CONCLUSIONS: The coaching strategies described in this study can inform the work of clinical nurse specialists and other advanced practice registered nurses charged with advancing interprofessional collaborative practice. Future research is recommended to examine the efficacy of strategies and develop a comprehensive model of healthcare team coaching.

A Multisite Health System Survey to Assess Organizational Context to Support Evidence-Based Practice.

BACKGROUND: Implementation and sustainability of a culture of evidence-based practice (EBP) require a systematic approach. A baseline assessment of the organizational context can inform implementation efforts. AIMS: To examine organizational hospital context and provider characteristics associated with EBP readiness and to describe EBP context across hospitals. METHODS: A nonexperimental descriptive correlational design was used to conduct a web-based survey of direct-care registered nurses (N = 701) and nurse managers (N = 94) across a large Midwestern multisite healthcare system using the Alberta Context Tool (ACT). RESULTS: Many significant relationships existed among nurse characteristics and ACT domains, including age (lower age had higher Leadership, Evaluation, and Formal Interactions), education (graduate education had lower Social Capital than a bachelor's or associate degree), role (direct-care nurses had lower Culture than managers and lower Social Capital), and work status (full-time employees had lower Evaluation and Social Capital). EBP context across type of hospitals is similar, with marginal differences in Social Capital and Organizational Slack (higher in critical access hospitals). LINKING EVIDENCE TO ACTION: Assessing organizational context to support EBP is the first step in developing and enhancing a sustainable culture of inquiry. The ACT has been tested across countries, settings, and healthcare disciplines to measure perception of readiness of the practice environment toward EBP. Optimal organizational context is essential to support EBP and sustain the use of evidence in professional nursing practice. Nursing leaders can use baseline assessment information to identify strengths and opportunities to enhance EBP implementation. Enhancing organizational context across nurse characteristics (e.g., age, role, and work status) to acknowledge nurses' contributions, balance nurses' personal and work life, enhance connectedness, and support work culture is beneficial. Fostering development of Social Capital in nurses is needed to influence EBP readiness. A systematic and standardized approach to foster EBP across health systems is key to successful implementation.

Building Evidence-Based Nursing Practice Capacity in a Large Statewide Health System: A Multimodal Approach.

Integration of evidence-based practice (EBP) into the culture of a healthcare organization is essential to provide safe patient care and promote a thriving culture for the nurses within the healthcare organization. Collaboration and utilization of both clinical and academic experts facilitate the removal of barriers to EBP. This article describes the successful partnership between a healthcare system and school of nursing in executing a 3-phased multimodal approach to an EBP training program.

Empowering Nurses to Lead Interprofessional Collaborative Practice Environments Through a Nurse Leadership Institute.

A year-long Nurse Leadership Institute (NLI) for emerging leaders in primary care clinics and acute care environments was developed, implemented, and evaluated. The NLI's goal was to foster empowerment in interprofessional collaborative practice environments for nurses in the three cohorts of NLIs. The NLI was framed around the Five Leadership Practices of modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart. To create a professional learning environment, foster community, and enhance leadership skills, the Lean In Circle materials developed by Sandberg were adapted for content reorganization and discussion. Minimal literature exists specifically addressing nursing leadership professionals' development based on Sandberg's Circle materials. The findings of the three NLI cohorts reported in this article begin to fill this existing knowledge gap. Participants reported a significant increase in leadership skills. Recommendations for refinement of future NLI offerings are provided. J Contin Educ Nurs. 2018;49(2):61-71.

Burkholderia cenocepacia-induced delay of acidification and phagolysosomal fusion in cystic fibrosis transmembrane conductance regulator (CFTR)-defective macrophages.

The Burkholderia cepacia complex (Bcc) is a group of opportunistic bacteria chronically infecting the airways of patients with cystic fibrosis (CF). Several laboratories have shown that Bcc members, in particular B. cenocepacia, survive within a membrane-bound vacuole inside phagocytic and epithelial cells. We have previously demonstrated that intracellular B. cenocepacia causes a delay in phagosomal maturation, as revealed by impaired acidification and slow accumulation of the late phagolysosomal marker LAMP-1. In this study, we demonstrate that uninfected cystic fibrosis transmembrane conductance regulator (CFTR)-defective macrophages or normal macrophages treated with a CFTR-specific drug inhibitor display normal acidification. However, after ingestion of B. cenocepacia, acidification and phagolysosomal fusion of the bacteria-containing vacuoles occur in a lower percentage of CFTR-negative macrophages than CFTR-positive cells, suggesting that loss of CFTR function contributes to enhance bacterial intracellular survival. The CFTR-associated phagosomal maturation defect was absent in macrophages exposed to heat-inactivated B. cenocepacia and macrophages infected with a non-CF pathogen such as Salmonella enterica, an intracellular pathogen that once internalized rapidly traffics to acidic compartments that acquire lysosomal markers. These results suggest that not only a defective CFTR but also viable B. cenocepacia are required for the altered trafficking phenotype. We conclude that CFTR may play a role in the mechanism of clearance of the intracellular infection, as we have shown before that B. cenocepacia cells localized to the lysosome lose cell envelope integrity. Therefore, the prolonged maturation arrest of the vacuoles containing B. cenocepacia within cftr(-/-) macrophages could be a contributing factor in the persistence of the bacteria within CF patients.

Burkholderia cenocepacia requires the RpoN sigma factor for biofilm formation and intracellular trafficking within macrophages.

Chronic respiratory infections by Burkholderia cenocepacia in cystic fibrosis patients are associated with increased morbidity and mortality, but virulence factors determining the persistence of the infection in the airways are not well characterized. Using a chronic pulmonary infection model, we previously identified an attenuated mutant with an insertion in a gene encoding an RpoN activator protein, suggesting that RpoN and/or components of the RpoN regulon play a role in B. cenocepacia virulence. In this study, we demonstrate that a functional rpoN gene is required for bacterial motility and biofilm formation in B. cenocepacia K56-2. Unlike other bacteria, RpoN does not control flagellar biosynthesis, as evidenced by the presence of flagella in the rpoN mutant. We also demonstrate that, in macrophages, the rpoN mutant is rapidly trafficked to lysosomes while intracellular wild-type B. cenocepacia localizes in bacterium-containing vacuoles that exhibit a pronounced delay in phagolysosomal fusion. Rapid trafficking to the lysosomes is also associated with the release of red fluorescent protein into the vacuolar lumen, indicating loss of bacterial cell envelope integrity. Although a role for RpoN in motility and biofilm formation has been previously established, this study is the first demonstration that the RpoN regulon in B. cenocepacia is involved in delaying phagolysosomal fusion, thereby prolonging bacterial intracellular survival within macrophages.

Mitochondrial proteins Bnip3 and Bnip3L are involved in anthrax lethal toxin-induced macrophage cell death.

Anthrax lethal toxin (LeTx) induces rapid cell death of RAW246.7 macrophages. We recently found that a small population of these macrophages is spontaneously and temporally refractory to LeTx-induced cytotoxicity. Analysis of genome-wide transcripts of a resistant clone before and after regaining LeTx sensitivity revealed that a reduction of two closely related mitochondrial proteins, Bcl-2/adenovirus E1B 19-kDa interacting protein 3 (Bnip3) and Bnip3-like (Bnip3L), correlates with LeTx resistance. Down-regulation of Bnip3 and Bnip3L was also found in "toxin-induced resistance" whereby sublethal doses of LeTx induce resistance to subsequent exposure to cytolytic toxin doses. The role of Bnip3 and Bnip3L in LeTx-induced cell death was confirmed by showing that overexpression of either Bnip3 or Bnip3L rendered the resistant cells susceptible to LeTx, whereas down-regulation of Bnip3 and Bnip3L in wild-type macrophages conferred resistance. The down-regulation of Bnip3 and Bnip3L mRNAs by LeTx occurred at both transcriptional and mRNA stability levels. Inhibition of the p38 pathway by lethal factor was responsible for the destabilization of Bnip3/Bnip3L mRNAs as confirmed by showing that p38 inhibitors stabilized Bnip3 and Bnip3L mRNAs and conferred resistance to LeTx cytotoxicity. Therefore, Bnip3/Bnip3L play a crucial role in LeTx-induced cytotoxicity, and down-regulation of Bnip3/Bnip3L is a mechanism of spontaneous or toxin-induced resistance of macrophages.

Intracellular survival of Burkholderia cenocepacia in macrophages is associated with a delay in the maturation of bacteria-containing vacuoles.

Strains of the Burkholderia cepacia complex (Bcc) are opportunistic bacteria that can cause life-threatening infections in patients with cystic fibrosis and chronic granulomatous disease. Previous work has shown that Bcc isolates can persist in membrane-bound vacuoles within amoeba and macrophages without bacterial replication, but the detailed mechanism of bacterial persistence is unknown. In this study, we have investigated the survival of the Burkholderia cenocepacia strain J2315 within RAW264.7 murine macrophages. Strain J2315 is a prototypic isolate of the widespread and transmissible ET12 clone. Unlike heat-inactivated bacteria, which reach lysosomes shortly after internalization, vacuoles containing live B. cenocepacia J2315 accumulate the late endosome/lysosome marker LAMP-1 and start fusing with lysosomal compartments only after 6 h post internalization. Using fluorescent fluid-phase probes, we also demonstrated that B. cenocepacia-containing vacuoles continued to interact with newly formed endosomes, and maintained a luminal pH of 6.4 +/- 0.12. In contrast, vacuoles containing heat-inactivated bacteria had an average pH of 4.8 +/- 0.03 and rapidly merged with lysosomes. Additional experiments using concanamycin A, a specific inhibitor of the vacuolar H+-ATPase, revealed that vacuoles containing live bacteria did not exclude the H+-ATPase. This mode of bacterial survival did not require type III secretion, as no differences were found between wild type and a type III secretion mutant strain. Collectively, our results suggest that intracellular B. cenocepacia cause a delay in the maturation of the phagosome, which may contribute to facilitate bacterial escape from the microbicidal activities of the host cell.

Burkholderia cepacia complex isolates survive intracellularly without replication within acidic vacuoles of Acanthamoeba polyphaga.

We have previously demonstrated that isolates of the Burkholderia cepacia complex can survive intracellularly in murine macrophages and in free-living Acanthamoeba. In this work, we show that the clinical isolates B. vietnamiensis strain CEP040 and B. cenocepacia H111 survived but did not replicate within vacuoles of A. polyphaga. B. cepacia-containing vacuoles accumulated the fluid phase marker Lysosensor Blue and displayed strong blue fluorescence, indicating that they had low pH. In contrast, the majority of intracellular bacteria within amoebae treated with the V-ATPse inhibitor bafilomycin A1 localized in vacuoles that did not fluoresce with Lysosensor Blue. Experiments using bacteria fluorescently labelled with chloromethylfluorescein diacetate demonstrated that intracellular bacteria remained viable for at least 24 h. In contrast, Escherichia coli did not survive within amoebae after 2 h post infection. Furthermore, intracellular B. vietnamiensis CEP040 retained green fluorescent protein within the bacterial cytoplasm, while this protein rapidly escaped from the cytosol of phagocytized heat-killed bacteria into the vacuolar lumen. Transmission electron microscopy analysis confirmed that intracellular Burkholderia cells were structurally intact. In addition, both Legionella pneumophila- and B. vietnamiensis-containing vacuoles did not accumulate cationized ferritin, a compound that localizes within the lysosome. Thus, our observations support the notion that B. cepacia complex isolates can use amoebae as a reservoir in the environment by surviving without intracellular replication within an acidic vacuole that is distinct from the lysosomal compartment.

Design, synthesis, and characterization of peptide nanostructures having ion channel activity.

We report the synthesis and the functional studies of multiple crown alpha-helical peptides designed to form artificial ion channels. The approach combines the versatility of solid phase peptide synthesis, the conformational predictability of peptidic molecules, and the solution synthesis of crown ethers with engineerable ion-binding abilities. Several biophysical methods were employed to characterize the activity and the mode of action of these crown peptide nanostructures. The 21 residue peptides bearing six 21-EC-7 turned out to facilitate the translocation of ions in a similar fashion to natural ion channels.