Workplace empowerment,collaborative work relationships,and job strain in nurse practitioners

PURPOSE: To test a theoretical model linking nurse practitioners' (NPs) perceptions of workplace empowerment, collaboration with physicians and managers, and job strain. DATA SOURCES: A predictive, nonexperimental design was used to test a model in a sample of 63 acute care NPs and 54 primary care NPs working in Ontario, Canada. The Conditions of Work Effectiveness Questionnaire, the Collaborative Behaviour Scale--Parts A (physicians) and B (managers), and the Job Content Questionnaire were used to measure the major study variables. CONCLUSIONS: The results of this study support the proposition that the extent to which NPs have access to information, support, resources, and opportunities in their work environment has an impact on the extent of collaboration with physicians and managers, and ultimately, the degree of job strain experienced in the work setting. Primary care NPs have significantly higher levels of workplace empowerment, collaboration with managers, and lower levels of job strain than acute care NPs. IMPLICATIONS: These findings will benefit NPs and nursing leaders in their efforts to create empowering work environments that enable NPs to provide excellent quality patient care and achieve organizational outcomes.     

The distress experienced by people with type 2 diabetes

With diabetes an ever-increasing problem across the developed world, a great deal of research has been carried out into the effects of the disease on the patient. Yet despite the fact that type 1 diabetes accounts for only a relatively small proportion of worldwide cases, it has been the focus of research attention. This study aimed to investigate the distress associated with type 2 diabetes, whether gender differences existed in the impact of type 2 diabetes and how men and women viewed dietary management. A multi-method, two-stage research approach was taken. Quantitative data were obtained using the Problem Areas in Diabetes (PAID) questionnaire, and no statistically significant gender difference was identified. Worrying about the future, the possibility of complications and feelings of guilt or anxiety when 'off-track' with diabetes management were sources of significant distress. Treatment mode, length of time diagnosed with diabetes and age were significant factors which impacted on the emotional distress experienced by the individual. A subsample of respondents took part in the survey. Behavioural impact, emotional impact and fear of complications were major themes identified in the interviews. Views of the dietary management of diabetes were also explored within the focus groups and three broad categories identified: dietary restrictions, value judgements and the influence of others. Awareness by health-care professionals of factors influencing adaptation to diabetes is recommended.     

Medical care inconsistent with patients' treatment goals: association with 1-year Medicare resource use and survival

OBJECTIVES: To describe how frequently seriously ill persons perceive that the care they receive is inconsistent with treatment preferences and the effect on 1-year resource utilization. SETTING: Five U.S. teaching hospitals. DESIGN: Secondary analysis of interview data. PARTICIPANTS: Seriously ill Medicare beneficiaries. MEASUREMENTS: Interviews about patients' preferred approaches to care and whether they perceived care was consistent with these preferences. Part A and B costs for up to 1 year, adjusted for cost differences across hospitals and over time and for 1-year survival. RESULTS: Forty percent of the 1,185 study patients expressed a preference for treatment to focus on extending life, whereas 60% expressed a preference for comfort care. Eighty-six percent of the patients who wanted aggressive treatment reported that care was consistent with their preferences, but only 41% of those who preferred comfort care reported that care was consistent with their preferences. More than one-third of those with a preference for comfort care (35%) reported that the medical care that they received was inconsistent with their goals; 24% were unsure of treatment goals. Those who preferred comfort care but believed that their care was inconsistent with their wishes had higher estimated mean 1-year costs than those who believed that their care was consistent with their wishes (92,442 US dollars vs 52,098 US dollars, P < .001). Even after adjusting for differences in disease severity, age, gender, race, functional status, income, and years of education, adjusted costs were 1.4 times (95% confidence interval = 1.2-1.6) higher. However, 1-year survival was lower in these patients who stated that care was consistent with their preference to focus on comfort care than for those who wished to receive comfort care and stated that care was not consistent with their preference (38% vs 55% 1-year survival, P < .001). CONCLUSION: More than one in three seriously ill persons who prefer comfort care believe that their medical care is at odds with their preference that treatment focus on palliation. Such discord was associated with higher 1-year healthcare costs and increased survival.     

Adapting a transforming growth factor beta-related tumor protection strategy to enhance antitumor immunity

Transforming growth factor beta (TGF-beta), a pleiotropic cytokine that regulates cell growth and differentiation, is secreted by many human tumors and markedly inhibits tumor-specific cellular immunity. Tumors can avoid the differentiating and apoptotic effects of TGF-beta by expressing a nonfunctional TGF-beta receptor. We have determined whether this immune evasion strategy can be manipulated to shield tumor-specific cytotoxic T lymphocytes (CTLs) from the inhibitory effects of tumor-derived TGF-beta. As our model we used Epstein-Barr virus (EBV)-specific CTLs that are infused as treatment for EBV-positive Hodgkin disease but that are vulnerable to the TGF-beta produced by this tumor. CTLs were transduced with a retrovirus vector expressing the dominant-negative TGF-beta type II receptor HATGF-betaRII-Deltacyt. HATGF-betaRII-Deltacyt- but not green fluorescence protein (eGFP)-transduced CTLs was resistant to the antiproliferative and anticytotoxic effects of exogenous TGF-beta. Additionally, receptor-transduced cells continued to secrete cytokines in response to antigenic stimulation. TGF-beta receptor ligation results in phosphorylation of Smad2, and this pathway was disrupted in HATGF-betaRII-Deltacyt-transduced CTLs, confirming blockade of the signal transduction pathway. Long-term expression of TGF-betaRII-Deltacyt did not affect CTL function, phenotype, or growth characteristics. Tumor-specific CTLs expressing HATGF-betaRII-Deltacyt should have a selective functional and survival advantage over unmodified CTLs in the presence of TGF-beta-secreting tumors and may be of value in treatment of these diseases.     

Effect of nitric oxide modulation on systemic haemodynamics and platelet activation determined by P-selectin expression

Inhibiting platelet and endothelial nitric oxide production favours platelet adhesion and aggregation, and arterial vasoconstriction. This study investigated the effect of NG-nitro-l-arginine methyl ester (L-NAME), a stereospecific inhibitor of nitric oxide synthesis, on P-selectin expression on platelets, platelet-derived microparticles and platelet-leucocyte aggregates, and on soluble P-selectin levels. Twelve healthy male volunteers were infused intravenously with L-NAME and then with a 10% solution of either l- or d-arginine. Blood pressure responses were recorded and whole blood and serum collected at baseline and after each infusion. P-selectin expression was analysed in all samples by flow cytometry. Serum levels of soluble P-selectin were batch analysed using an enzyme-linked immunosorbent assay at the end of the study. P-selectin expression on platelets, platelet-derived microparticles and platelet-leucocyte aggregates did not vary significantly from baseline levels following the infusion of L-NAME or l- or d-arginine. However, endothelial nitric oxide synthase inhibition caused a marked elevation of arterial blood pressure (P < 0.01) that was restored to pretreatment values by l- but not d-arginine. Serum levels of the soluble form decreased significantly (P = 0.001) following the infusion of l- and d-arginine compared with samples taken at baseline and following L-NAME infusion. In conclusion, inhibition of constitutive nitric oxide synthase in the endothelium and platelets produced significant increases in blood pressure but did not alter platelet membrane expression of P-selectin.