Success indicators and barriers to acute nurse practitioner role implementation in four Ontario hospitals.

Changes in healthcare environmental factors resulted in the introduction of the acute care nurse practitioner (ACNP) role in Ontario. The purpose of the study was to identify success indicators, barriers, and recommendations for role implementation to assist healthcare providers to develop strategies for integrating ACNPs into teams. Acute care nurse practitioners (n = 14), physicians (n = 14), administrators (n = 12), and staff nurses (n = 48) from four tertiary care hospitals completed a researcher-developed, self-administered questionnaire with fixed and open-ended questions. Specialty practice areas (cardiac/critical care, geriatrics, and nephrology) were matched within the four sites. Acute care nurse practitioners (n = 14), physicians (n = 12), administrators (n = 8), and staff nurses (n = 34) responded. The major indicator by all groups for successful role implementation was level of preparation. Barriers included lack of mentorship and knowledge of the role, and perceived lack of support from administration and physicians. Themes reflecting impact on patient care were improved communication and attention to patient care issues. Respondents accepted the role, concluding that enhanced continuity of care was a result. Role clarity before and during implementation would assist team members in understanding the purpose and value of the role, thus easing the integration of the ACNP into the healthcare team.

Consortium approach for nurse practitioner education.

In 1995, a 10-university consortium approach to deliver a post-baccalaureate primary care nurse practitioner programme funded by the Ontario Ministry of Health was launched throughout Ontario, Canada. A combination of traditional and distance teaching methods, in English and French, were used. A 5-year research project was initiated to evaluate the entire programme, the effect of nurse practitioners on patient and health-care system outcomes and examine practice patterns. Participants included deans and directors (n = 10), regional co-ordinators (n = 5) and course developers, some of whom were also course professors (n = 8). This article is a report of the evaluation of the consortium programme after the first year from the perspective of groups involved in implementation and delivery. Results of qualitative analyses of participant perceptions from researcher-led focus groups and asynchronous electronic interviews provided the framework for the evaluation, and revealed the rationale for the consortium method, strengths, limitations and recommendations. Sharing ideas, resources and delivery and increased student access in remote areas were perceived as positive outcomes. Limitations included the short time period to develop programme content, identify and plan for distance education resources, and too little communication between universities and students. Researchers concluded that the consortium approach was effective for nurse practitioner education. Key factors identified for programme planning were communication, resources, curriculum and workload. Included among the recommendations was to allow sufficient time for role and course development before beginning a similar programme.

Development and evaluation of a pathophysiology CD-ROM for nurse practitioner distance education.

Increasing interest in computer-mediated learning technologies has prompted educators to incorporate them into many learning environments; however, there is still little evaluative evidence to support their effectiveness. This report describes the development and evaluation of an instructional CD-ROM on pathophysiology for Nurse Practitioner students. Researcher-designed questionnaires were used to assess the characteristics of our students, and to solicit their ratings of the CD-ROM on ease of use, clarity of instruction, interest, and convenience of the program, using 5-point Likert scales. The respondents indicated that the package was easy and convenient to use, with high technical quality, and of a level challenging to some but not all of the students. On-line quizzes were most highly rated. There were also some indications of higher levels of achievement among users than among nonusers. These data suggest use of CD-ROM as a distance education strategy can be effective for Nurse Practitioner students.

Pathophysiology and implications for treatment of acute respiratory distress syndrome.

Acute respiratory distress syndrome is a complex group of signs and symptoms caused by direct or indirect lung injury. In spite of decades of research, it is still associated with a high mortality rate. Pathogenesis of this disease is related to alveolar endothelial and epithelial cell injury and associated release and sequestration of inflammatory mediators and cells, including cytokines and neutrophils, respectively. Pharmacologic interventions have been largely unsuccessful, and ventilation strategies to support oxygenation while limiting ventilator associated lung injury have not demonstrated any significant reductions in the mortality rate. However, novel therapies are in development, based on the knowledge of the pathologic processes of acute respiratory distress syndrome. In this article an overview of the disease process and mediator involvement is presented, followed by a review of pharmacologic and ventilation treatments currently in use or under study.

Effect of caffeine on metabolism, exercise endurance, and catecholamine responses after withdrawal.

In this study the effects of acute caffeine ingestion on exercise performance, hormonal (epinephrine, norepinephrine, insulin), and metabolic (free fatty acids, glycerol, glucose, lactate, expired gases) parameters during short-term withdrawal from dietary caffeine were investigated. Recreational athletes who were habitual caffeine users (n = 6) (maximum oxygen uptake 54.5 +/- 3.3 ml x kg-1 x min-1 and daily caffeine intake 761.3 +/- 11.8 mg/day) were tested under conditions of no withdrawal and 2-day and 4-day withdrawal from dietary caffeine. There were seven trials in total with a minimum of 10 days between trials. On the day of the exercise trial, subjects ingested either dextrose placebo or 6 mg/kg caffeine in capsule form 1 h before cycle ergometry to exhaustion at 80-85% of maximum oxygen uptake. Test substances were assigned in a random, double-blind manner. A final placebo control trial completed the experiment. There was no significant difference in any measured parameters among days of withdrawal after ingestion of placebo. At exhaustion in the 2- and 4-day withdrawal trials, there were significant increases in plasma norepinephrine in response to caffeine ingestion. Caffeine-induced increases in serum free fatty acids occurred after 4 days and only at rest. Subjects responded to caffeine with increases in plasma epinephrine (P < 0.05) at exhaustion and prolonged exercise time in all caffeine trials compared with placebo, regardless of withdrawal from caffeine. It is concluded that increased endurance is unrelated to hormonal or metabolic changes and that it is not related to prior caffeine habituation in recreational athletes.

Caffeine and exercise: metabolism and performance.

Caffeine ingestion prior to prolonged exercise delays fatigue. However, the mechanisms involved are very unclear. Caffeine is associated with elevated plasma epinephrine but the metabolic impact of this is uncertain. Glycogen sparing occurs in active muscle, at least in the first few minutes, but studies have generally failed to demonstrate enhanced fat metabolism. The demethylation of caffeine by the hepatic cytochrome P-450 oxygenases begins within minutes and dimethylxanthines (especially paraxanthine) are generated. These compounds appear in the plasma within an hour of caffeine ingestion and may have effects on tissues that have been attributed to caffeine and/or epinephrine. While the most widely supported theory is that caffeine and other methylxanthines are adenosine receptor antagonists, this action alone cannot explain all of the observed responses. Nevertheless, habituation to and withdrawal from caffeine are associated with up and down regulation of adenosine receptors. One study demonstrated marked differences in the effects of caffeine on the plasma concentrations of epinephrine and dimethylxanthines between caffeine users and nonusers. Caffeine is clearly a very active drug that has many effects on humans including increasing exercise endurance. This can be associated with muscle glycogen sparing and elevated plasma epinephrine, but the underlying mechanisms are unknown.

Caffeine metabolism and epinephrine responses during exercise in users and nonusers.

This study compared the caffeine (CAF) metabolism and the catecholamine and metabolic responses of users and nonusers of caffeine after acute ingestion of caffeine (5 mg/kg) during 1 h of steady-state exercise (50% maximal oxygen consumption). Nonusers (n = 7) completed two exercise trials after ingesting either CAF (5 mg/kg) or placebo (PL). Users (n = 7) underwent three trials designed to control caffeine use and abstained from voluntary CAF intake for 18 days. After 4 days they had a PL trial and in the following 14 days they were given random 6 days of CAF (2 x 2.5 mg.kg-1 x day-1) or PL ingestion followed in each case on the 7th day by a CAF exercise trial identical to that of the nonusers. In nonusers CAF increased (P < 0.05) plasma epinephrine (EPI) concentration above PL values during exercise. Users did not exhibit any increased EPI with CAF, but the EPI response to exercise in all three trials was twofold greater than that of the nonusers' PL trial (P < 0.05). In all trials both groups had identical norepinephrine responses. The groups had similar plasma and urinary caffeine concentration, but plasma dimethylxanthines varied; the users had greater (P < 0.05) theophylline concentration, and the nonusers had a greater (P < 0.05) rise in paraxanthine (PX) concentration. The users and nonusers' plasma free fatty acids (FFA), glycerol and respiratory exchange ratio were similar after ingestion of CAF. Although PX may increase FFA in resting subjects, in this study PX concentrations in nonusers varied from that of the users, yet FFA data were similar.(ABSTRACT TRUNCATED AT 250 WORDS)