Computerization and its contribution to care quality improvement: the nurses' perspective

BACKGROUND

Despite the widely held belief that the computerization of hospital medical systems contributes to improved patient care management, especially in the context of ordering medications and record keeping, extensive study of the attitudes of medical staff to computerization has found them to be negative. The views of nursing staff have been barely studied and so are unclear. The study reported here investigated the association between nurses' current computer use and skills, the extent of their involvement in quality control and improvement activities on the ward and their perception of the contribution of computerization to improving nursing care. The study was made in the context of a Joint Commission International Accreditation (JCIA) in a large tertiary medical center in Israel. The perception of the role of leadership commitment in the success of a quality initiative was also tested for.

METHODS

Two convenience samples were drawn from 33 clinical wards and units of the medical center. They were questioned at two time points, one before the JCIA and a second after JCIA completion. Of all nurses (N=489), 89 were paired to allow analysis of the study data in a before-and-after design. Thus, this study built three data sets: a pre-JCIA set, a post-JCIA set and a paired sample who completed the questionnaire both before and after JCIA. Data were collected by structured self-administered anonymous questionnaire.

RESULTS

After the JCIA the participants ranked the role of leadership in quality improvement, the extent of their own quality control activity, and the contribution of computers to quality improvement higher than before the JCIA. Significant Pearson correlations were found showing that the higher the rating given to quality improvement leadership the more nurses reported quality improvement activities undertaken by them and the higher nurses rated the impact of computerization on the quality of care. In a regression analysis quality improvement leadership and computer use/skills accounted for 30% of the variance in the perceived contribution of computerization to quality improvement.

CONCLUSIONS

(a) The present study is the first to show a relationship between organizational leadership and computer use by nurses for the purpose of improving clinical care. (b) The nurses' appreciation of the contribution computerization can make to data management and to clinical care quality improvement were both increased by the JCI accreditation process.

Factors affecting the actions and emotional reactions of nursing teachers following encounters with students who present them with Internet information

OBJECTIVE

The Internet is a preferred source of information for nursing students. The purpose of the research was to identify teachers' reactions towards students who present them with information retrieved from the Internet.

METHOD

A total of 137 nursing teachers from 15 nursing schools in Israel were surveyed by a questionnaire. The dependent variable was nursing teachers' actions following encounters with students who present them with information from the Internet. Independent variables were: teacher's emotional reactions, teachers' Internet efficacy, Internet anxiety, and perceived student Internet efficacy.

RESULTS

The intensity of positive emotional reactions was the only predictor of teachers' actions towards Internet information retrieved by students. When teachers perceived students as having higher Internet efficacy, their emotional reactions were more positive and they took more actions. Teachers' Internet anxiety was negatively correlated with their positive emotional reactions and actions. No correlation was found between nursing teachers' Internet self efficacy and their reactions or actions following an encounter with students presenting Internet information. Positive emotional reactions mediated correlations between teachers' Internet anxiety, perceived student Internet efficacy, and teachers' actions.

CONCLUSIONS

Nursing teachers' positive emotions foster openness and acceptance of Internet information retrieved by students.

Organizational safety culture and medical error reporting by Israeli nurses

PURPOSE

To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses.

DESIGN

Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%).

METHODS

The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data.

FINDINGS

Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance.

CONCLUSIONS

This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level.

CLINICAL RELEVANCE

A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety.

An update of childhood genetic disorders

PURPOSE

Thousands of single gene, mitochondrial, and chromosomal disorders have been described in children. The purpose of this article is twofold. The first is to increase nurses' awareness of new developments in genetic disorders that are commonly seen in practice and taught in schools of nursing. The second is to illustrate important genetic concepts of relevance to nurses who care for infants, children, or adolescents.

ORGANIZING CONSTRUCT

This article is organized into four sections: one that describes new developments in a well-known disorder, a second that discusses the process and potential outcomes of diagnosing a very rare disorder, and the third and fourth sections that describe select conditions caused by single gene mutations.

METHODS

Clinical expertise was paired with literature review to present evidence-based current information. Implications for nursing practice are highlighted throughout the article. Citations of publicly available evidence-based online resources are used so nurses can continue to use these in their practices.

FINDINGS

Diagnosis and treatment strategies for children with genetic disorders are rapidly changing. While it is impossible to stay current in all disorders, resources are available to help nurses provide evidence-based care to children with genetic disorders.

CLINICAL RELEVANCE

Nurses have an important role in the early identification of children with genetic disorders and in facilitating their access to appropriate services and resources. Nurses can also help families understand why genetic testing may be necessary and assure families are informed throughout the process.

Intentions of nurses and nursing students to tell the whole truth to patients and family members

AIMS AND OBJECTIVES

To investigate the intentions of nurses and nursing students to telling the truth to patients and families, based on the Theory of Planned Behavior which examines intention to perform behaviours.

BACKGROUND

In recent decades, the perception that patients have a moral and legal right to truthful and reliable information has become dominant. However, the study of telling the truth to non-oncology patients has received scant attention and little is known about the intention of nurses and nursing students to tell the truth.

DESIGN

A cross-sectional design.

METHODS

We used a scenario-based questionnaire, illustrating eight different situations in which nurses/nursing students are asked to tell the truth to a patient or family member regarding a devastating disease with which the patient is afflicted. Data were analysed using the Mann-Whitney U-test and ridge regression.

RESULTS

The sample included 150 participants, 110 registered nurses and 40 third year nursing students, with a response rate of 87%. The results show that nurses and nursing students intend to tell the whole truth even if this is not easy for them. Nurses more than students think that it is important to tell the whole truth and intend to do so. Head nurses tend to tell the truth more than staff nurses. For nurses, the components of the Theory of Planned Behaviour predicted intention to tell the truth, whereas among students subjective norms were the only predictor of intention.

CONCLUSION

The Theory of Planned Behaviour is a powerful predictor of nurse intention to tell the whole truth to patients and their families. Students perceive social pressure as the most important incentive of their intention to tell the truth.

RELEVANCE TO CLINICAL PRACTICE

Nurses and nursing students should receive additional training in dealing with various situations involving truth telling.

Suggested components of the curriculum for nurses and midwives to enable them to develop essential knowledge and skills in genetics

Nurses and midwives need to develop specific knowledge and skills in genetics to enable them to offer appropriate healthcare in a range of non-specialist settings. Studies on the topic indicate that while nurses acknowledged the importance of genetics knowledge to their work, both their knowledge and confidence in using such information are poor. Despite the existence of competence frameworks, it appears that educators have struggled with the need to integrate genetics into nursing and midwifery curricula. An expert workshop on genetics education was held to determine the essential components of genetics knowledge and skills that should be incorporated into the pre-registration nursing curriculum in European countries. In this paper we present the essential topics for nurse and midwife pre-registration education and suggest ways in which genetics might be incorporated into the nursing and midwifery curriculum.

What makes patients perceive their health care worker as an epistemic authority?

Health care workers' (HCW) perceived epistemic authority (EA) may have an effect on patient decision-making and compliance. The present study investigated the hypotheses that higher EA is attributed to staff perceived to be experts; to physicians rather than nurses; to HCWs who recommend taking a test more than to the ones who make no recommendation. The study was based on a factorial 2 × 2 × 2 within-between subjects design. The questionnaire presented four scenarios, each illustrating a HCW presenting information on a devastating genetic disease. The three variables manipulated were: HCW expertise, HCW role, and making a recommendation or not. After each scenario participants were asked questions about the EA they attributed to the HCW in the scenario. The results show main effects for perceived expertise and recommendation/no recommendation on the level of EA attributed. Expert nurses were judged to have the same high EA as expert physicians. But expert physicians who recommended taking a test were judged as having significantly higher EA than expert physicians who made no recommendation. Among nurses who made no recommendation, expert nurses were evaluated as having significantly higher EA than novices. Since expert nurses were perceived to have equal expertise as expert physicians, it follows that information given by both nurses and physicians can reduce patient uncertainty.

Calpastatin upregulation in Mycoplasma hyorhinis-infected cells is promoted by the mycoplasma lipoproteins via the NF-κB pathway

Mycoplasma hyorhinis frequently contaminates cultured cells, with effects on synthetic and metabolic pathways. We demonstrated for the first time that contamination of cells by a strain of M. hyorhinis (NDMh) results in increased levels of calpastatin (the endogenous inhibitor of the ubiquitous Ca(2+) -dependent protease calpain). We now show that the calpastatin upregulation by NDMh in neuroblastoma SH-SY5Y cells resides in the NDMh lipoprotein fraction (LPP), via the NF-κB transcription pathway. NF-κB activation requires dissociation of the cytoplasmic NF-κB/IκB complex followed by NF-κB translocation to the nucleus. NDMh-LPP induced translocation of the NF-κB RelA subunit to the nucleus and upregulated calpastatin. RelA translocation and calpastatin elevation were prevented when dissociation of the NF-κB/IκB complex was inhibited either by transfection with the non-phosphorylatable IκB mutant ΔNIκBα, or by using PS1145, an inhibitor of the IκB kinase (IKK complex). Increased calpastatin levels attenuate calpain-related amyloid-β-peptide and Ca(2+) -toxicity (these are central to the pathogenesis of Alzheimer's Disease). LPP-induced elevation of calpastatin provides an example of effects on non-inflammatory intracellular proteins, the outcome being significant alterations in host cell functions. Since calpastatin level is important in the control of calpain activity, mycoplasmal LPP may be of interest in treating some pathological processes involving excessive calpain activation.

Reactions of staff members and lay people to family presence during resuscitation: the effect of visible bleeding, resuscitation outcome and gender

AIM

This article is a report on a study conducted to examine the views of healthcare professionals and lay people regarding the effect of family presence during resuscitation on both the staff performing the resuscitation and the relatives who witness it.

BACKGROUND

Family presence during resuscitation is controversial. Although many professional groups in different countries have recently issued position statements about the practice and have recommended new policy moves, the Israel Ministry of Health has not issued guidelines on the matter.

METHODS

Study design is factorial within-between subjects. Data were collected in Israel in 2008 from a convenience sample of 220 lay people and 201 healthcare staff (52 physicians and 149 nurses) using a questionnaire based on eight different resuscitation scenarios and manipulating blood involvement and resuscitations outcome. Data were analysed using one-way analysis of variance.

FINDINGS

Overall, both staff and lay people perceived family presence during resuscitation negatively. Visible bleeding and an unsuccessful outcome significantly influenced both staff's and lay people's perceptions. Female physicians and nurses reacted more negatively to family presence than did male physicians and nurses; lay men responded more negatively than lay women.

CONCLUSIONS

Changing the current negative perceptions of family presence at resuscitation requires (a) establishing a new national policy, (b) educating healthcare staff to the benefits of the presence of close relatives and (c) training staff to support relatives who want to be present.

Self-epistemic authority and nurses' reactions to medical information that is retrieved from Internet sites of different credibility

This cross-sectional study investigated nurses' reactions to Internet medical information that was retrieved from sources of different scientific credibility and the association between self-epistemic authority and these reactions. The participants filled in questionnaires on their reactions to Internet medical information and self-epistemic authority. The nurses' reactions to Internet medical information from a highly credible source (Medline) correlated positively with self-epistemic authority. However, no such correlation was found with Internet medical information from a less credible Internet source (Ynet). Compared with the nurses without an academic degree, the nurses with an academic degree had more positive reactions to the information that was retrieved from Medline. The reactions to the medical information that was retrieved from Ynet did not differ by the education of the nurses. This study shows that nurses' reactions to different sources of Internet information vary according to their level of self-epistemic authority and education. As patients' use of Internet medical information is increasing, nurses need to expand their expertise in the various professional and popular medical information sites. Such skills will help to reduce any negative feeling that might arise when they encounter patients who present medical information from the Internet.

Nurse or physician: whose recommendation influences the decision to take genetic tests more?

AIM

This paper is a report of a study conducted to explore factors influencing the decision to take genetic carrier testing.

BACKGROUND

Genetic testing has become a popular means of elucidating the risk of giving birth to a sick/disabled child but what influences prospective parents to take genetic tests or not is unclear.

METHODS

The study was based on a factorial 2 x 2 x 2 within-between subjects design. The questionnaire presented four scenarios, each illustrating a healthcare worker presenting information on a devastating genetic disease. The variables manipulated were: the health care worker's expertise (novice vs. expert), the recommender's role (nurse vs. physician) and type of recommendation (recommendation vs. no recommendation). After each scenario participants were asked their own intention to take the test and their intention to recommend a friend to take the test. Data were collected in 2007.

RESULTS

Altogether 156 questionnaires were collected. Expert nurses and expert physicians were accorded the same level of compliance. However, a novice physician's recommendation to take a genetic test was complied with as much as an expert physician's, whereas a novice nurse's recommendation was less accepted than that of an expert nurse. When no recommendation was made, more compliance with the nurse was found (i.e. less intention to take the test).

CONCLUSION

Genetic information should be presented to the public with caution to avoid over-testing. For the public to accept a nurse's recommendation, the nurse has to be perceived as an expert; therefore, expert nurses' proficiency should be made clear.

Mycoplasma hyorhinis upregulates calpastatin and inhibits calpain-dependent proteolysis in SH-SY5Y neuroblastoma cells

Mycoplasmas often contaminate cultured cells, leading to alterations in cellular gene expression, protein synthesis, signal transduction and metabolic pathways. Mycoplasmal contamination is often unnoticed, so that mycoplasma-induced alterations in cell functions may not be appreciated, unless specifically studied. Here, we show for the first time that contamination of SH-SY5Y cells by Mycoplasma hyorhinis leads to increased levels of calpastatin (the endogenous inhibitor of the Ca(2+)-dependent protease calpain), resulting in inhibition of Ca(2+)-induced calpain activation and inhibition of calpain-promoted proteolysis in the mycoplasmal-infected cells. Calpain activity is recovered upon calpastatin removal from extracts of contaminated cells. The calpain-calpastatin system has been implicated in a variety of physiological and pathological processes (signal transduction, motility, cell cycle, cell differentiation, membrane damage and apoptosis). Because the ratio of calpastatin to calpain is an important factor in the control of calpain activity within the cell, the elevated calpastatin may protect the mycoplasma-infected cells against certain types of damage (e.g. caused by high Ca(2+)). Thus, our results are important for studies on the modulation of host cells by mycoplasmas, and relevant to the pathobiology of processes involving mycoplasmal infections. The mycoplasma-infected cells provide a system for identifying factors that participate in the regulation of cellular calpastatin.

Characterization of WRSs2 and WRSs3, new second-generation virG(icsA)-based Shigella sonnei vaccine candidates with the potential for reduced reactogenicity

Live, attenuated Shigella vaccine candidates, such as Shigella sonnei strain WRSS1, Shigella flexneri 2a strain SC602, and Shigella dysenteriae 1 strain WRSd1, are attenuated principally by the loss of the VirG(IcsA) protein. These candidates have proven to be safe and immunogenic in volunteer trials and in one study, efficacious against shigellosis. One drawback of these candidate vaccines has been the reactogenic symptoms of fever and diarrhea experienced by the volunteers, that increased in a dose-dependent manner. New, second-generation virG(icsA)-based S. sonnei vaccine candidates, WRSs2 and WRSs3, are expected to be less reactogenic while retaining the ability to generate protective levels of immunogenicity seen with WRSS1. Besides the loss of VirG(IcsA), WRSs2 and WRSs3 also lack plasmid-encoded enterotoxin ShET2-1 and its paralog ShET2-2. WRSs3 further lacks MsbB2 that reduces the endotoxicity of the lipid A portion of the bacterial LPS. Studies in cell cultures and in gnotobiotic piglets demonstrate that WRSs2 and WRSs3 have the potential to cause less diarrhea due to loss of ShET2-1 and ShET2-2 as well as alleviate febrile symptoms by loss of MsbB2. In guinea pigs, WRSs2 and WRSs3 were as safe, immunogenic and efficacious as WRSS1.

Calpain activates caspase-8 in neuron-like differentiated PC12 cells via the amyloid-beta-peptide and CD95 pathways

The neurotoxic amyloid-beta-peptide (Abeta) is important in the pathogenesis of Alzheimer's disease (AD). Calpain (Ca(2+)-dependent protease) and caspase-8 (the initiating caspase for the extrinsic, receptor-mediated apoptosis pathway) have been implicated in AD/Abeta toxicity. We previously found that Abeta promoted degradation of calpastatin (the specific endogenous calpain inhibitor); calpastatin degradation was prevented by inhibitors of either calpain or caspase-8. The results implied a cross-talk between the two proteases and suggested that one protease was responsible for the activity of the other one. We now report on the previously unrecognized caspase-8 activation by calpain. In neuron-like differentiated PC12 cells, calpain promotes active caspase-8 formation from procaspase-8 via the Abeta and CD95 pathways, along with degradation of the procaspase-8 processing inhibitor caspase-8 (FLICE)-like inhibitory protein, short isoform (FLIP(S)). Inhibition of calpain (by pharmacological inhibitors and by overexpression of calpastatin) prevents the cleavage of procaspase-8 to mature, active caspase-8, and inhibits FLIP(S) degradation in the Abeta-treated and CD95-triggered cells. Increased cellular Ca(2+) per se results in calpain activation but does not lead to caspase-8 activation or FLIP(S) degradation. The results suggest that procaspase-8 and FLIP(S) association with cell membrane receptor complexes is required for calpain-induced caspase-8 activation. The results presented here add to the understanding of the roles of calpain, caspase-8, and CD95 pathway in AD/Abeta toxicity. Calpain-promoted activation of caspase-8 may have implications for other types of CD95-induced cell damage, and for nonapoptotic functions of caspase-8. Inhibition of calpain may be useful for modulating certain caspase-8-dependent processes.

Factors affecting nurses' attitudes in Israel toward patients who present them with Internet medical information

Nurses regularly encounter patients bringing with them medical data from the Internet. The purpose of the present study was to examine the prevalence of these encounters, nurses' attitudes to these patients, and the factors that might influence their attitudes. A cross-sectional study of a convenience sample of 110 nurses (32 practical nurses, 35 registered nurses and 43 academically trained nurses). The main variables measured were: attitudes toward patients presenting Internet information, professional self-esteem, and three indices of Internet use. The results show that most nurses had encountered patients presenting Internet medical information and held positive attitudes to them. Nurses with such experience had more positive attitudes than nurses with no such experience. Professional self-esteem and indices of Internet use were also positively correlated to favorable attitudes to these patients. Regression analysis showed that professional self-esteem and Internet self-efficacy predicted attitudes to these patients. Since the number of patients presenting Internet information can only multiply, there is a need to prepare and train nurses for encounters with such patients.

Nurses attitudes towards the informed patient

The widespread use of the Internet for health information has resulted in knowledgeable clients referred to as "informed patients". Many patients bring the information they downloaded from the Internet to the appointments with the health care workers.

OBJECTIVES

The present study examined the prevalence of nurses' encounters and attitudes to these patients and factors that might influence attitudes.

METHOD

A cross-sectional study of a convenience sample of 110 nurses in Israel was conducted. The main variables measured were: attitudes, professional self-esteem, and two indices of Internet use.

RESULTS

The results show that most nurses held positive attitudes towards patients presenting Internet Medical Information. Nurses with prior experience had more positive attitudes than nurses with no such experience. Professional self-esteem and Internet use were also positively correlated to positive attitudes to these patients.

CONCLUSIONS

Since patients search the Internet for medical information, there is a need to prepare and train nurses to be Internet literate in order to be prepared for encounters with such patients.

Calpastatin overexpression attenuates amyloid-beta-peptide toxicity in differentiated PC12 cells

Amyloid beta peptide (Abeta) plays a major role in the pathogenesis of Alzheimer's disease (AD). Abeta is toxic to neurons, possibly through causing initial synaptic dysfunction and neuronal membrane dystrophy, promoted by increased cellular Ca(2+). Calpain (Ca(2+)-dependent protease) and caspase have been implicated in AD. Previously, we used calpain and caspase pharmacological inhibitors to study effects of Abeta25-35 (sAbeta) on neuronal-like differentiated PC12 cells. We reported that sAbeta-treated cells exhibited calpain activation and protein degradation (due to both calpain and caspase-8). We have now found that overexpression of the calpain specific inhibitor calpastatin in differentiated PC12 cells significantly inhibited the sAbeta-induced calpain activation and decreased the protease activity. Calpastatin overexpression inhibited the sAbeta-promoted degradation of fodrin, protein kinase Cepsilon, beta-catenin (membrane structural proteins and proteins involved in signal transduction pathways), and prevented the sAbeta-induced alteration of neurite structure (manifested by varicosities). Overexpression of calpastatin also inhibited Ca(2+)-promoted calpain activation and protein degradation; this is consistent with the notion that the Abeta-induced increase in calpain activity results from a rise in cellular Ca(2+), provided the calpastatin level is not so high as to strongly inhibit calpain. Carrying out transfection without selection allowed the comparison in the same culture of calpastatin-overexpressing with non-overexpressing cells. In cultures transfected with green fluorescent protein (GFP)-calpastatin plasmid, calpastatin overexpression (indicated by GFP-labeling) led to inhibition in sAbeta-induced membrane propidium iodide (PI) permeability, whereas non-transfected, GFP-unlabeled cells exhibited PI permeability. Overall, the results demonstrate that the effects of Abeta-toxicity studied here were attenuated to a large extent by calpastatin overexpression, indicating that the protease calpain is involved in Abeta-toxicity (obviating a primary, direct role for caspases). Increased expression of calpastatin and/or decrease in calpain may serve as one of the means for ameliorating some of the early symptoms of AD.

Calpastatin levels affect calpain activation and calpain proteolytic activity in APP transgenic mouse model of Alzheimer's disease

The intracellular Ca(2+)-dependent protease calpain and the specific calpain endogenous inhibitor calpastatin are widely distributed, with the calpastatin/calpain ratio varying among tissues and species. Increased Ca(2+) and calpain activation have been implicated in Alzheimer's disease (AD), with scant data available on calpastatin/calpain ratio in AD. Information is lacking on calpain activation and calpastatin levels in transgenic mice that exhibit AD-like pathology. We studied calpain and calpastatin in Tg2576 mice and in their wild type littermates (control mice). We found that in control mice calpastatin level varies among brain regions; it is significantly higher in the cerebellum than in the hippocampus, frontal and temporal cortex, whereas calpain levels are similar in all these regions. In the Tg2576 mice, calpain is activated, calpastatin is diminished, and calpain-dependent proteolysis is observed in brain regions affected in AD and in transgenic mice (especially hippocampus). In contrast, no differences are observed between the Tg2576 and the control mice in the cerebellum, which does not exhibit AD-like pathology. The results are consistent with the notion that a high level of calpastatin in the cerebellum renders the calpain in this brain region less liable to be activated; in the other brain parts, in which calpastatin is low, calpain is more easily activated in the presence of increased Ca(2+), and in turn the activated calpain leads to further diminution in calpastatin (a known calpain substrate). The results indicate that calpastatin is an important factor in the regulation of calpain-induced protein degradation in the brains of the affected mice, and imply a role for calpastatin in attenuating AD pathology. Promoting calpastatin expression may be used to ameliorate some manifestations of AD.