Residency Programs and Clinical Leadership Skills Among New Saudi Graduate Nurses.

Nurse residency programs have been adopted by health care organizations to assist new graduate nurses with daily challenges such as intense working environments, increasing patient acuity, and complex technologies. Overall, nurse residency programs are proven beneficial in helping nurses transition from the student role to independent practitioners and bedside leaders. The purpose of this study was to assess the impact of residency programs on leadership skills of new Saudi graduate nurses who completed a residency program compared to new Saudi graduate nurses who did not participate in residency programs. The study design was cross-sectional involving a convenience sample (n = 98) of new graduate nurses from three hospitals in Saudi Arabia. The Clinical Leadership Survey was used to measure the new graduate nurses' clinical leadership skills based on whether they completed a residency program or not. Descriptive statistics, correlation, and multiple linear regression analyses were conducted to examine leadership skills in this sample of new Saudi graduate nurses. A significant difference was found between residents and nonresidents in their leadership skills (t = 10.48, P = .000). Specifically, residents were significantly more likely to show higher levels of leadership skills compared to their counterparts. Attending a residency program was associated with a significant increase in clinical leadership skills. The findings of this study indicate that there is a need to implement more residency programs in hospitals of Saudi Arabia. It is imperative that nurse managers and policy makers in Saudi Arabia consider these findings to improve nurses' leadership skills, which will in turn improve patient care. Further research should examine how residency programs influence new graduate nurses' transition from student to practitioner with regard to clinical leadership skills in Saudi Arabia.

Clinical decision-making among new graduate nurses attending residency programs in Saudi Arabia.

PURPOSE: This study examined the impact of residency programs on clinical decision-making of new Saudi graduate nurses who completed a residency program compared to new Saudi graduate nurses who did not participate in residency programs. DESIGN: This descriptive study employed a convenience sample (N=98) of new graduate nurses from three hospitals in Saudi Arabia. A self-administered questionnaire was used to collect data. Clinical decision-making skills were measured using the Clinical Decision Making in Nursing Scale. METHODS: Descriptive statistics, independent t-tests, and multiple linear regression analysis were utilized to examine the effect of residency programs on new graduate nurses' clinical decision-making skills. FINDINGS: On average, resident nurses had significantly higher levels of clinical decision-making skills than non-residents (t=23.25, p=0.000). Enrollment in a residency program explained 86.9% of the variance in total clinical decision making controlling for age and overall grade point average. CONCLUSIONS: The findings of this study support evidence in the nursing literature conducted primarily in the US and Europe that residency programs have a positive influence on new graduate nurses' clinical decision-making skills. CLINICAL RELEVANCE: This is the first study to examine the impact of residency programs on clinical decision-making among new Saudi graduate nurses who completed a residency program. The findings of this study underscore the need for the development and implementation of residency programs for all new nurses.

The impact of residency programs on new nurse graduates' clinical decision-making and leadership skills: a systematic review.

BACKGROUND: Health care institutions have adapted residency programs to help new graduate nurses to become fully competent and transition from a student nurse to an independent practicing nurse and a bedside leader. OBJECTIVES: The study's aim is to review the literature on the impact of residency programs on new graduate nurses' clinical decision-making and leadership skills. REVIEW METHODS: An electronic search was conducted between 1980 and 2013 using databases of the scientific literature in Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo using a range of keywords. Information gathered was evaluated for relevance. RESULTS: Thirteen studies that met the inclusion criteria were used in this systematic review. In several studies considered in this review, residency programs were developed to improve new graduates skills and promote their transition into the nursing workforce. In fact, the transition programs reduced turnover in that first year of practice and promoted professional growth of the new graduate such as hand-on nursing skills, clinical decision-making and leadership skills, satisfaction, and retention. CONCLUSION: There is a need for effective residency programs that are designed to prepare new graduate nurses in providing safe, competent and effective patient care.

A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition.

Healthcare spending in the United States is the highest in the world, yet quality indicators such as life expectancy and infant mortality lag other countries. U.S. reforms are under way to lower costs and raise quality of care, notably the Patient Protection and Affordable Care Act (PPACA). Value-based purchasing (VBP) and programs for reducing the incidence of hospital-acquired conditions (HACs) and hospital readmissions represent initial changes. With these programs, overarching themes are to coordinate care during and beyond hospitalization and to ensure that physicians and hospitals are aligned in their treatment strategies. Hospital malnutrition represents a large, hidden, and costly component of medical care; hospital administrators and caregivers alike must harness the benefits of nutrition as a vital component of healthcare. Medical, nursing, and allied health training programs must find places in their curricula to increase awareness of nutrition and promote knowledge of best-practice nutrition interventions. Hospitals use dietitians and nutrition support teams as critical members of the patient care team, but more work needs to be done to disseminate and enforce best nutrition practices. Such training, nutrition interventions, and practice changes can help prevent and treat malnutrition and thus help avert HACs, reduce hospital readmissions, lower infection and complication rates, and shorten hospital stays. Nutrition care is an effective way to reduce costs and improve patient outcomes. This article calls hospital executives and bedside clinicians to action: recognize the value of nutrition care before, during, and after hospitalization, as well as develop training programs and policies that promote nutrition care.

Esperanto for histones: CENP-A, not CenH3, is the centromeric histone H3 variant.

The first centromeric protein identified in any species was CENP-A, a divergent member of the histone H3 family that was recognised by autoantibodies from patients with scleroderma-spectrum disease. It has recently been suggested to rename this protein CenH3. Here, we argue that the original name should be maintained both because it is the basis of a long established nomenclature for centromere proteins and because it avoids confusion due to the presence of canonical histone H3 at centromeres.

The role of intergenerational influence in waste education programmes: the THAW project.

Whilst the education of young people is often seen as a part of the solution to current environmental problems seeking urgent attention, it is often forgotten that their parents and other household members can also be educated/influenced via home-based educational activities. This paper explores the theory of intergenerational influence in relation to school based waste education. Waste Watch, a UK-based environmental charity (www.wastewatch.org.uk), has pioneered a model that uses practical activities and whole school involvement to promote school based action on waste. This methodology has been adopted nationally. This paper outlines and evaluates how effective school based waste education is in promoting action at a household level. The paper outlines Waste Watch's 'Taking Home Action on Waste (THAW)' project carried out for two and half years in Rotherham, a town in South Yorkshire, England. The project worked with 6705 primary age children in 39 schools (44% of primary schools in the project area) to enable them to take the "reduce, reuse and recycle message" home to their families and to engage these (i.e. families) in sustainable waste management practices. As well as substantial increases in students' knowledge and understanding of waste reduction, measurement of the impact of the project in areas around 12 carefully chosen sample schools showed evidence of increased participation in recycling and recycling tonnages as well as declining levels of residual waste. Following delivery of the project in these areas, an average increase of 8.6% was recorded in recycling set out rates which led to a 4.3% increase in paper recycling tonnages and an 8.7% increase in tonnages of cans, glass and textiles collected for recycling. Correspondingly, there was a 4.5% fall in tonnages of residual waste. Waste Watch's THAW project was the first serious attempt to measure the intergenerational influence of an education programme on behaviour at home (i.e. other than schools' own waste). It clearly shows that household recycling behaviour can be positively impacted by intergenerational influence via a practical school-based waste education model. However, although the model could potentially have a big impact if rolled out nationally, it will require seed funding and the long-term durability of the model has not yet been fully quantified.

Open courses: one view of the future of online education.

Open courses provide the entire course (lectures, assignments, syllabus, student's discussions, and student's projects) online without revealing student's personal information. We report on our experience in managing 8 open online courses at http://nhs.georgetown.edu/open. Open courses have several advantages over password protected courses: (1) they are available through search engines and thus reduce the program's marketing cost, (2) continuous feedback from the web enables rapid improvements to the course, (3) customer relationship tools, tied to open courses, radically reduce faculty time spent on one-on-one emails while increasing student/faculty interaction. We provide details of one course. In 15 weeks, 803 emails were received by and 1181 sent by the faculty (all within 6% of a working week and 82% savings of faculty time). We show how open courses can be accessed through search engines, how students questions are answered on the web and how student projects, in popular sites such as You Tube and Face Book, improve course marketing. The paper reports that student satisfaction with three open online courses delivered overall several semesters was high.

Roles of polymerization dynamics, opposed motors, and a tensile element in governing the length of Xenopus extract meiotic spindles.

Metaphase spindles assemble to a steady state in length by mechanisms that involve microtubule dynamics and motor proteins, but they are incompletely understood. We found that Xenopus extract spindles recapitulate the length of egg meiosis II spindles, by using mechanisms intrinsic to the spindle. To probe these mechanisms, we perturbed microtubule polymerization dynamics and opposed motor proteins and measured effects on spindle morphology and dynamics. Microtubules were stabilized by hexylene glycol and inhibition of the catastrophe factor mitotic centromere-associated kinesin (MCAK) (a kinesin 13, previously called XKCM) and destabilized by depolymerizing drugs. The opposed motors Eg5 and dynein were inhibited separately and together. Our results are consistent with important roles for polymerization dynamics in regulating spindle length, and for opposed motors in regulating the relative stability of bipolar versus monopolar organization. The response to microtubule destabilization suggests that an unidentified tensile element acts in parallel with these conventional factors, generating spindle shortening force.

Bipolarization and poleward flux correlate during Xenopus extract spindle assembly.

We investigated the mechanism by which meiotic spindles become bipolar and the correlation between bipolarity and poleward flux, using Xenopus egg extracts. By speckle microscopy and computational alignment, we find that monopolar sperm asters do not show evidence for flux, partially contradicting previous work. We account for the discrepancy by describing spontaneous bipolarization of sperm asters that was missed previously. During spontaneous bipolarization, onset of flux correlated with onset of bipolarity, implying that antiparallel microtubule organization may be required for flux. Using a probe for TPX2 in addition to tubulin, we describe two pathways that lead to spontaneous bipolarization, new pole assembly near chromatin, and pole splitting. By inhibiting the Ran pathway with excess importin-alpha, we establish a role for chromatin-derived, antiparallel overlap bundles in generating the sliding force for flux, and we examine these bundles by electron microscopy. Our results highlight the importance of two processes, chromatin-initiated microtubule nucleation, and sliding forces generated between antiparallel microtubules, in self-organization of spindle bipolarity and poleward flux.

Evaluating Medicaid HMOs when encounter data are missing: case of developmentally delayed children.

In evaluating Medicaid Health Maintenance Organizations (HMOs), crucial information regarding severity of illness of patients is often missing--in part because encounter data are not available. If we assume that patients are either in the HMO or in fee-for-service (FFS) plans (i.e., no in or out migration); then severity of HMO patients can be deduced from encounters of FFS patients. We applied this approach to effectiveness of HMO services for developmentally delayed children. Data supported the assumption of a closed system. Data also showed that over 12 months, severity of FFS patients declined. Therefore, we inferred that the HMO was attracting sicker patients. The HMO was paid less than FFS plan, despite the fact that it attracted sicker patients.

HIPAA: update on rule revisions and compliance requirements.

Due to the highly technical requirements for HIPAA compliance and the numerous administrative and clinical functions and processes involved, guidance from experts who are knowledgeable about systems design and use to secure private data is necessary. In health care organizations, this will require individuals who are knowledgeable about clinical processes and those who understand health information technology, security, and privacy to work together to establish an entity's compliance plans and revise operations and practices accordingly. As a precondition of designing such systems, it is essential that covered entities understand the HIPAA's statutory requirements and timeline for compliance. An organization's success in preparing for HIPAA will depend upon an active program of assessment, planning, and implementation. Compliance with security and privacy standards can be expected to increase costs initially. However, greater use of EDI is expected to reduce costs and enhance revenues in the long run if processes and systems are improved. NOTE: Special protection for psychotherapy notes holds them to a higher standard of protection. Notes used only by a psychotherapist are not intended to be shared with anyone and are not considered part of the medical record.

Drosophila APC2 and Armadillo participate in tethering mitotic spindles to cortical actin.

Proper positioning of mitotic spindles ensures equal allocation of chromosomes to daughter cells. This often involves interactions between spindle and astral microtubules and cortical actin. In yeast and Caenorhabditis elegans, some of the protein machinery that connects spindles and cortex has been identified but, in most animal cells, this process remains mysterious. Here, we report that the tumour suppressor homologue APC2 and its binding partner Armadillo both play roles in spindle anchoring during the syncytial mitoses of early Drosophila embryos. Armadillo, alpha-catenin and APC2 all localize to sites of cortical spindle attachment. APC2-Armadillo complexes often localize with interphase microtubules. Zeste-white 3 kinase, which can phosphorylate Armadillo and APC, is also crucial for spindle positioning and regulates the localization of APC2-Armadillo complexes. Together, these data suggest that APC2, Armadillo and alpha-catenin provide an important link between spindles and cortical actin, and that this link is regulated by Zeste-white 3 kinase.

Control of microtubule dynamics by Stu2p is essential for spindle orientation and metaphase chromosome alignment in yeast.

Stu2p is a member of a conserved family of microtubule-binding proteins and an essential protein in yeast. Here, we report the first in vivo analysis of microtubule dynamics in cells lacking a member of this protein family. For these studies, we have used a conditional Stu2p depletion strain expressing alpha-tubulin fused to green fluorescent protein. Depletion of Stu2p leads to fewer and less dynamic cytoplasmic microtubules in both G1 and preanaphase cells. The reduction in cytoplasmic microtubule dynamics is due primarily to decreases in both the catastrophe and rescue frequencies and an increase in the fraction of time microtubules spend pausing. These changes have significant consequences for the cell because they impede the ability of cytoplasmic microtubules to orient the spindle. In addition, recovery of fluorescence after photobleaching indicates that kinetochore microtubules are no longer dynamic in the absence of Stu2p. This deficiency is correlated with a failure to properly align chromosomes at metaphase. Overall, we provide evidence that Stu2p promotes the dynamics of microtubule plus-ends in vivo and that these dynamics are critical for microtubule interactions with kinetochores and cortical sites in the cytoplasm.

Merotelic kinetochore orientation is a major mechanism of aneuploidy in mitotic mammalian tissue cells.

In mitotic cells, an error in chromosome segregation occurs when a chromosome is left near the spindle equator after anaphase onset (lagging chromosome). In PtK1 cells, we found 1.16% of untreated anaphase cells exhibiting lagging chromosomes at the spindle equator, and this percentage was enhanced to 17.55% after a mitotic block with 2 microM nocodazole. A lagging chromosome seen during anaphase in control or nocodazole-treated cells was found by confocal immunofluorescence microscopy to be a single chromatid with its kinetochore attached to kinetochore microtubule bundles extending toward opposite poles. This merotelic orientation was verified by electron microscopy. The single kinetochores of lagging chromosomes in anaphase were stretched laterally (1.2--5.6-fold) in the directions of their kinetochore microtubules, indicating that they were not able to achieve anaphase poleward movement because of pulling forces toward opposite poles. They also had inactivated mitotic spindle checkpoint activities since they did not label with either Mad2 or 3F3/2 antibodies. Thus, for mammalian cultured cells, kinetochore merotelic orientation is a major mechanism of aneuploidy not detected by the mitotic spindle checkpoint. The expanded and curved crescent morphology exhibited by kinetochores during nocodazole treatment may promote the high incidence of kinetochore merotelic orientation that occurs after nocodazole washout.

Emergency surgery: atavistic refuge of the general surgeon?

A prospective audit of emergency soft-tissue surgery for an eight-week period revealed that general surgical emergency operations were more than twice as common as those undertaken in other soft-tissue specialties. The audit reveals that emergency general surgery needs an increase in resources, an increase in available staff and an increase in the role of the consultant general surgeon on call. An alternative solution would be to admit soft-tissue emergencies by specialty and develop specialist emergency services.

The effect of stopping smoking on cervical Langerhans' cells and lymphocytes.

OBJECTIVE: To investigate the effects of stopping smoking on cervical Langerhans' cells and lymphocytes. DESIGN: Prospective intervention study. SETTING: A large family planning clinic in central London. POPULATION: Women volunteers prepared to attempt to give up smoking for six months. Their most recent cervical smear showed no abnormality greater than mild dyskaryosis. METHODS: The women were seen at three-month intervals for six months. Reduction in smoking was assessed by self-reporting and validated by salivary cotinine concentrations. Colposcopy and a biopsy of a normal area were performed at the first and last visits. Any area of abnormality was also biopsied at the final visit. Langerhans' cells and lymphocytes were counted. MAIN OUTCOME MEASURES: Proportional changes in counts of Langerhans' cells and lymphocytes with reduction in smoking. RESULTS: Reduction in smoking by 20 to 40 cigarettes per day was significantly associated with a reduction of between 6% and 16% in counts of Langerhans cells, CD8 and total lymphocytes. Heavy smoking was significantly associated (P = 0.02) with an increased chance of persistent human papillomavirus infection. The presence of candida was associated with significantly higher counts of between 41% and 47% in total lymphocytes and CD8 lymphocytes. In contrast, the presence of anaerobic vaginosis was associated with significantly lower counts of between 16% and 30% in Langerhans cells, CD4 and CD8 lymphocytes. CONCLUSIONS: This large intervention study has demonstrated a clear relationship between reduction in smoking and changes in cervical immune cell counts. Future studies need to take into account cytokine interactions, which recent studies suggest may be significant in the immune response to both human papillomavirus and cervical intraepithelial neoplasia and the ever-increasing complexity of the cell-mediated immune system of the cervix.

Budding yeast chromosome structure and dynamics during mitosis.

Using green fluorescent protein probes and rapid acquisition of high-resolution fluorescence images, sister centromeres in budding yeast are found to be separated and oscillate between spindle poles before anaphase B spindle elongation. The rates of movement during these oscillations are similar to those of microtubule plus end dynamics. The degree of preanaphase separation varies widely, with infrequent centromere reassociations observed before anaphase. Centromeres are in a metaphase-like conformation, whereas chromosome arms are neither aligned nor separated before anaphase. Upon spindle elongation, centromere to pole movement (anaphase A) was synchronous for all centromeres and occurred coincident with or immediately after spindle pole separation (anaphase B). Chromatin proximal to the centromere is stretched poleward before and during anaphase onset. The stretched chromatin was observed to segregate to the spindle pole bodies at rates greater than centromere to pole movement, indicative of rapid elastic recoil between the chromosome arm and the centromere. These results indicate that the elastic properties of DNA play an as of yet undiscovered role in the poleward movement of chromosome arms.

Patient safety and the need for professional and educational change.

Questionable quality of health care delivered in the United States has become a front-line issue, taking a strong place alongside more traditional concerns such as increasing costs and access to care. Given that nurses comprise the largest component of the health care workforce, safety and error reduction in health care are central concerns for the profession.

Bioterrorism: a renewed public health threat.

In the aftermath of the terrorist attacks of September 11, the United States is coming to terms with new and urgently felt public health and safety concerns related to the threat of bioterrorism. The recent history and the legislative agenda emerging to prevent, monitor, and respond to bioterrorism in the United States are described.