Measuring the outputs of nursing research and development in Australia: the researchers

It is vital for nurses to publish in order to provide evidence of their practice and to increase the knowledge base of their discipline. This paper is one of two that reports on an investigation of the nursing research published by Australian authors from 1995-2000 in 11 nursing journals based in Australia, the UK and the USA. The focus of this article is on the researchers drawn from a total of 509 articles that were content analysed and categorised according to topics of research, paradigm, methods used and funding acknowledgment. The researchers were analysed on the basis of gender, discipline, employment base and location. Publications had from one to 10 authors, averaging two, with 26 authors claiming 23.6% of research articles. The most common discipline area was nursing and universities were the leading area of employment. Authorship was not limited to capital cities reflecting the spread of university campuses in rural areas. Research papers made up 12.5% of possible articles, supporting the notion that few nurses publish research papers in the refereed general nursing journals we focused on.

Measuring the outputs of Australian nursing research published 1995-2000

AIMS

To analyse the research published in refereed nursing journals by Australian authors from 1995 to 2000.

BACKGROUND

Analysis of the research topics and types of methodologies used by Australian nurse researchers has not been recently undertaken. The study was similar to an analysis of United Kingdom (UK) nursing research between 1988 and 1995 to allow comparison between the two countries.

DESIGN

A quantitative approach analysed the research abstracts for the topic researched, source of data, location of data collection, paradigm and methodology used and funding source.

RESULTS

A total of 509 articles from 11 generalist Australian and UK nursing journals were analysed. The highest numbers of articles were published in Australian Journal of Advanced Nursing and Journal of Advanced Nursing. The most popular topics were education of nurses (18.7%, n=95) and practice issues relating to patient care (15.3%, n=78). However, scant attention was paid to major Australian health issues. Most research was undertaken in the hospital setting (55.8%, n=247). Data were most often drawn from nurses themselves (40.7%, n=206), followed by patients (25.5%, n=129). Both quantitative (41%, n=203) and qualitative approaches (47%, n=230) were employed. A minority of studies acknowledged any funding (14.9%, n=76).

CONCLUSIONS

Research findings need to be applied in practice to improve patient care. Nurse researchers need to publish their findings and align their research interests to meet national health priorities. They need to be involved in setting these health priorities to ensure that nursing has a place in health research.

Our interest is swelling: a collaborative venture to establish the world's first free public screening for lymphoedema

This article describes the collaborative processes involved in the implementation of a free public health screening program for people at risk of lymphoedema following the removal of lymph nodes during surgery to control breast, prostate and other cancers, or injury. The planning phase of the program is described with emphasis on the need to secure a well situated venue, the commitment of a cohort of key health professionals, service club and lay volunteers, and the need to carefully target and publicise the event widely. The implementation phase requires careful consideration of the physical layout of the event, the direction and management of the flow of human traffic, information and equipment requirements, and recognition that screening programs place people in vulnerable positions. Effective communication skills are essential, as is a knowledge of where people can be referred should the need arise. A budget is provided together with discussion regarding the success of the program and recommendations for future consideration such as the need to target men to attend screening and for long term follow up of the outcomes.

Engendering change: empowering nurse academics to take part in a university research culture

Any school of nursing, which is building upon a college-based teaching culture to create and maintain a viable research culture within a university, must build from within its own resources. This paper outlines a strategic approach to create a research culture in one such school. We describe the empowerment philosophy based on critical and feminist approaches that underpinned our strategy in transforming what was a teaching based college of advanced education culture to that of a university in which both research and teaching are required of its staff. A climate to facilitate change was created and a research support structure was put in place. The success of the strategies can be assessed by the increased participation in research activities, enhanced productivity and evidence of increasing confidence of staff.

Cytoplasmic illuminations: in planta targeting of fluorescent proteins to cellular organelles

Use of the jellyfish green-fluorescent protein as an in vivo reporter is in the process of revolutionising plant cell biology. By fusing the protein to specific targeting peptides or to sequences of complete proteins, it is now possible to observe the location, structure, and dynamics of a number of intracellular organelles over extended periods of time. In this review we discuss the most recent developments and unexpected results originating from the targeting of this unique protein and its derivatives to elements of the cytoskeleton and to membrane-bounded organelles in a range of plant cell types.

A rab1 GTPase is required for transport between the endoplasmic reticulum and golgi apparatus and for normal golgi movement in plants

We describe a green fluorescent protein (GFP)-based assay for investigating membrane traffic on the secretory pathway in plants. Expression of AtRab1b(N121I), predicted to be a dominant inhibitory mutant of the Arabidopsis Rab GTPase AtRab1b, resulted in accumulation of a secreted GFP marker in an intracellular reticulate compartment reminiscent of the endoplasmic reticulum. This accumulation was alleviated by coexpressing wild-type AtRab1b but not AtRab8c. When a Golgi-targeted and N-glycosylated variant of GFP was coexpressed with AtRab1b(N121I), the variant also accumulated in a reticulate network and an endoglycosidase H-sensitive population appeared. Unexpectedly, expression of AtRab1b(N121I), but not of the wild-type AtRab1b, resulted in a reduction or cessation of vectorial Golgi movement, an effect that was reversed by coexpression of the wild type. We conclude that AtRab1b function is required for transport from the endoplasmic reticulum to the Golgi apparatus and suggest that this process may be coupled to the control of Golgi movement.

A rab1 GTPase is required for transport between the endoplasmic reticulum and golgi apparatus and for normal golgi movement in plants

We describe a green fluorescent protein (GFP)-based assay for investigating membrane traffic on the secretory pathway in plants. Expression of AtRab1b(N121I), predicted to be a dominant inhibitory mutant of the Arabidopsis Rab GTPase AtRab1b, resulted in accumulation of a secreted GFP marker in an intracellular reticulate compartment reminiscent of the endoplasmic reticulum. This accumulation was alleviated by coexpressing wild-type AtRab1b but not AtRab8c. When a Golgi-targeted and N-glycosylated variant of GFP was coexpressed with AtRab1b(N121I), the variant also accumulated in a reticulate network and an endoglycosidase H-sensitive population appeared. Unexpectedly, expression of AtRab1b(N121I), but not of the wild-type AtRab1b, resulted in a reduction or cessation of vectorial Golgi movement, an effect that was reversed by coexpression of the wild type. We conclude that AtRab1b function is required for transport from the endoplasmic reticulum to the Golgi apparatus and suggest that this process may be coupled to the control of Golgi movement.

A model for the future. Integration of the bachelor of nursing honours degree with the graduate nurse program

We describe an innovative integrated study pathway at the School of Nursing, Flinders University in which students can complete a Bachelor of Nursing Honours degree and Graduate Nurse Program in one year.

Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes

OBJECTIVES

This study analyzed the use of mechanical restraints and psychotropic medication in Alzheimer special care units (SCUs) in nursing homes.

METHODS

We analyzed 1993 data for more than 71,000 nursing home residents in 4 states, including more than 1,100 residents in 48 SCUs. The dependent variable in multinomial logistic regression was use of physical restraints or psychotropic medication. Models contained covariates representing facility and resident characteristics, and multivariate matching strategies were used to protect against selection bias.

RESULTS

Residents in SCUs did not differ from similar residents in traditional units in their likelihood of being physically restrained. Residents in SCUs were more likely to receive psychotropic medication.

CONCLUSIONS

With regard to the measures used in this research, the findings indicate that residents in the SCUs in the 4 study states did not receive quality of care superior to that provided to similar residents in traditional units. In fact, the results related to drug use raise the question of whether some may have received poorer care.

Biosynthesis and immunolocalization of Lewis a-containing N-glycans in the plant cell

We recently demonstrated the presence of a new asparagine-linked complex glycan on plant glycoproteins that harbors the Lewis a (Lea), or Galbeta(1-3)[Fucalpha(1-4)]GlcNAc, epitope, which in mammalian cells plays an important role in cell-to-cell recognition. Here we show that the monoclonal antibody JIM 84, which is widely used as a Golgi marker in light and electron microscopy of plant cells, is specific for the Lea antigen. This antigen is present on glycoproteins of a number of flowering and non-flowering plants, but is less apparent in the Cruciferae, the family that includes Arabidopsis. Lea-containing oligosaccharides are found in the Golgi apparatus, and our immunocytochemical experiments suggest that it is synthesized in the trans-most part of the Golgi apparatus. Lea epitopes are abundantly present on extracellular glycoproteins, either soluble or membrane bound, but are never observed on vacuolar glycoproteins. Double-labeling experiments suggest that vacuolar glycoproteins do not bypass the late Golgi compartments where Lea is built, and that the absence of the Lea epitope from vacuolar glycoproteins is probably the result of its degradation by glycosidases en route to or after arrival in the vacuole.

People who make a difference. Interview by Wendy L. Bonifazi

In last year's 20th anniversary issue, Contemporary started an annual tradition of honoring people whose innovative business practices, research, advocacy, and other efforts have shaped long term care. This year's four honorees have created groundbreaking tools for care, campaigned to promote the healthy growth of a fledgling form of care, and championed a vision for improving quality of life for residents.

Membrane trafficking in higher plant cells: GFP and antibodies, partners for probing the secretory pathway

Eukaryotic cells are characterised by the organised distribution of membrane bounded compartments in their cytoplasm. The endoplasmic reticulum (ER) and the Golgi apparatus (GA) are part of this endomembrane machinery. They are involved in protein flow, and are in charge of specific functions such as the assembly, sorting and transport of newly synthesised proteins, glycoproteins or polysaccharides to their final destination, where the macromolecules are recognised either for action, storage, deposition or degradation. The structural and functional relationship between the ER and GA in higher plants is still a matter of debate. Therefore, it was essential to develop probes that would specifically label proteins or glycoproteins of the endomembrane system in situ. Here we compare two complementary approaches to probe plant endomembranes; immunocytochemistry on fixed cells, and in vivo studies using the expression of GFP tagged chimeric proteins. The structural relationship between ER and GA as based on pharmacological approaches using the two systems is explored.

Stacks on tracks: the plant Golgi apparatus traffics on an actin/ER network

We have visualized the relationship between the endoplasmic reticulum (ER) and Golgi in leaf cells of Nicotiana clevelandii by expression of two Golgi proteins fused to green fluorescent protein (GFP). A fusion of the transmembrane domain (signal anchor sequence) of a rat sialyl transferase to GFP was targeted to the Golgi stacks. A second construct that expressed the Arabidopsis H/KDEL receptor homologue aERD2, fused to GFP, was targeted to both the Golgi apparatus and ER, allowing the relationship between these two organelles to be studied in living cells for the first time. The Golgi stacks were shown to move rapidly and extensively along the polygonal cortical ER network of leaf epidermal cells, without departing from the ER tubules. Co-localization of F-actin in the GFP-expressing cells revealed an underlying actin cytoskeleton that matched precisely the architecture of the ER network, while treatment of cells with the inhibitors cytochalasin D and N-ethylmaleimide revealed the dependency of Golgi movement on actin cables. These observations suggest that the leaf Golgi complex functions as a motile system of actin-directed stacks whose function is to pick up products from a relatively stationary ER system. Also, we demonstrate for the first time in vivo brefeldin A-induced retrograde transport of Golgi membrane protein to the ER.

A calcium pump at the higher plant nuclear envelope?

Evidence for a Ca2+-pump at the nuclear envelope (NE) in plant cells has been obtained using confocal and electron microscope immunocytochemistry and antibodies raised to a plant homologue of the mammalian SERCA pump. This is the first evidence suggesting an NE Ca2+-pump in plants. In addition to being localised with the NE in interphase, the antigen was localised to membrane derived from the NE and associated ER during mitosis, correlating with known Ca2+-pools. The work suggests that a SERCA pump is present at the NE of plant as well as animal cells.

N-glycans harboring the Lewis a epitope are expressed at the surface of plant cells

In plants, N-linked glycans are processed in the Golgi apparatus to complex-type N-glycans of limited size containing a beta(1,2)-xylose and/or an alpha(1,3)-fucose residue. Larger mono- and bi-antennary N-linked complex glycans have not often been described. This study has re-examined the structure of such plant N-linked glycans, and, through both immunological and structural data, it is shown that the antennae are composed of Lewis a (Le(a)) antigens, comprising the carbohydrate sequence Gal beta 1-3[Fuc alpha 1-4]GlcNAc. Furthermore, a fucosyltransferase activity involved in the biosynthesis of this antigen was detected in sycamore cells. This is the first characterization in plants of a Lewis antigen that is usually found on cell-surface glycoconjugates in mammals and involved in recognition and adhesion processes. Le(a)-containing N-linked glycans are widely distributed in plants and highly expressed at the cell surface, which may suggest a putative function in cell/cell communication.

Effects of residence in Alzheimer disease special care units on functional outcomes

CONTEXT

Alzheimer disease special care units (SCUs) in nursing homes are increasingly prevalent, but little is known about their effects on residents' outcomes.

OBJECTIVE

To analyze the effect of SCU residence on the rates at which residents decline in functional status.

DESIGN

A cohort of nursing home residents assessed at multiple points during about 1 year. Facility staff completed all assessments using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS).

SETTING

Medicare- or Medicaid-certified nursing facilities.

PATIENTS OR OTHER PARTICIPANTS

All nursing home residents in 1993 and early 1994 in Kansas, Maine, Mississippi, and South Dakota. Serial MDS assessments of 77337 residents in more than 800 facilities, including 1228 residents in 48 facilities with SCUs.

MAIN OUTCOME MEASURES

Decline in locomotion, transferring, toileting, eating, dressing, and a summary activities of daily living index; decline in urinary and bowel continence; and significant weight loss.

RESULTS

No statistically significant difference was observed in the speed of decline for residents in SCUs and traditional units in any of the 9 outcomes. Residents were matched on a variety of characteristics, and subgroup analyses were performed. In none did we observe a pattern of better outcomes among SCU residents.

CONCLUSIONS

Although SCUs may have provided unmeasured benefits to families and residents, it does not appear that those benefits included any slowing in the rates of functional decline experienced by individuals with dementia.

Development of the nursing home Resident Assessment Instrument in the USA

BACKGROUND

the nursing home Resident Assessment Instrument (RAI) includes a set of core assessment items, known as the Minimum Data Set (MDS), for assessment and care screening and more detailed Resident Assessment Protocols in 18 areas that represent common problem areas or risk factors for nursing home residents. Its primary use is clinical, to assess residents on admission to the nursing home, at least annually thereafter and on any significant change in status and to develop individualized, restorative plans of care.

AIM

to describe the content and development of the RAI, including US testing for MDS item reliability and validity of the RAI, and the results of a 4-year evaluation of the effects of its clinical use.

CONCLUSIONS

the evaluation found that implementation of the RAI was associated with significant improvements in a variety of measures of process quality, resident functional outcomes and reduced hospitalization. Other uses of the RAI data in the USA-including payment using resident classification systems and, with RAI-based outcome-oriented quality indicators, quality assurance activities-and the status of RAI use in other countries are also summarized.

Nursing homes in 10 nations: a comparison between countries and settings

AIM

to illustrate demographic differences and recent trends in the provision and structure of long-term care systems in the 10 countries participating in the Resident Assessment Instrument studies (Denmark, France, Iceland, Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA).

METHOD

data were assembled from government documents, statistical yearbooks and articles from journals; supplemental data on long-term care and nursing homes were solicited from colleagues.

RESULTS

All 10 countries are developed nations with high life-expectancies. Sweden has the oldest and Iceland the youngest population in this study, with Japan showing the highest ageing rates over the next three decades. Between 2 and 5% of elderly people reside in nursing homes. Interestingly, Iceland, as the 'youngest country' in this study, has the highest rate of institutionalization (living in residential or nursing homes), while the 'oldest country' (Sweden) has a low rate of institutionalization. In all countries the support ratio (number of elderly people per 100 younger adults) is high and increasing rapidly.

CONCLUSIONS

no relation appears to exist between the ageing status of a country and the number of nursing home beds. Institutionalization rates among the nations studied differ even more, due at least in part to differences in the organization and financing of long-term care services, in the amount of responsibility assumed in the care for disabled elderly people by each sector and the availability of long-term care beds. Facing a rapid ageing of their population, many countries are in the process of health and social care reforms.

Approaching cross-national comparisons of nursing home residents

METHOD

since the 1990 implementation of the US nursing home Resident Assessment Instrument (RAI), researchers in other nations have begun to use the RAI to assess institutionalized elders for payment, research, or planning purposes. We report comparative statistics representing institutionalized residents in seven nations, describing from several hundred to hundreds of thousands of residents.

RESULTS

significant differences are seen in age and length of stay, and in summary measures of physical and cognitive functioning and case-mix. Countries also differ in their homogeneity across nursing homes.

CONCLUSION

these differences strengthen the position that 'nursing home' does not provide a sound basis for cross-national comparisons, and should be replaced with resident-specific descriptors. This also suggests that cross-national comparisons need to adjust at the level of the individual resident for differences in resident populations.

A commitment to change: revision of HCFA's RAI

OBJECTIVE

To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI).

DESIGN

Independent dual assessment of residents of nursing facilities by staff nurses using a draft of Version 2.0 of the minimum data set (MDS).

SETTING AND PARTICIPANTS

A total of 187 randomly selected residents from 21 nursing homes in seven states volunteered to test Version 2.0 of the MDS.

MEASUREMENT

The full array of MDS assessment items included measures in the following areas: Background information, cognitive patterns, communication/hearing, vision, mood and behavior, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses, health condition, oral/nutritional status, dental status, skin condition, activity pursuit patterns, medications, special treatments and procedures, and discharge potential and overall status.

RESULTS

Evaluative data address issues of MDS item utility and reliability. For new items, almost all achieved a reasonably high-weighted Kappa interrater reliability; revised items also surpassed earlier items, and with the updated training materials, even the non-changed items had higher average reliability levels. Based on the success of the field test and the positive response of the industry, Version 2.0 of the RAI has been adopted, and HCFA has initiated a more long-range process to update further the RAI when necessary.

CONCLUSION

Findings support the reliability and clinical utility of the new and revised assessment items incorporated by HCFA in Version 2.0 of the MDS.

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality

OBJECTIVE

To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.

DESIGN

A quasi-experimental study using a complex, multistage probability-based sample design, with data collected before (1990) and after (1993) implementation of the RAI and other OBRA provisions.

SETTING AND PARTICIPANTS

Two independent cohorts (n > 2000) of residents in a random sample of 254 nursing facilities located in metropolitan statistical areas in 10 states.

INTERVENTION

OBRA-87 enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning, and the use of neuroleptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known as the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays issuing the regulations led to actual implementation of the RAI during the Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessing a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct staff caregivers for the sampled residents, and review of medical records, including physician's orders, treatment and care plans, nursing progress notes, and medication records. The RNs collected data on the characteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-OBRA or the 1993 post-OBRA cohort was assessed on the accuracy of information in the residents' medical records, the comprehensiveness of care plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using contingency tables and logistic regression and a special statistical software (SUDAAN) to assure proper variance estimation.

RESULTS

Overall, the process of care in nursing homes improved in several important areas. The accuracy of information in residents' medical records increased substantially, as did the comprehensiveness of care plans. In addition, several problematic care practices declined during this period, including use of physical restraints (37.4 to 28.1% (P < .001)) and indwelling urinary catheters (9.8 to 7% (P < .001)). There were also increases in good care practices, such as the presence of advanced directives, participation in activities, and use of toileting programs for residents with bowel incontinence. These results were sustained after controlling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavior management programs, preventive skin care, and provision of therapies were unaffected, or the differences were not statistically significant, after adjusting for changes in resident case-mix.

CONCLUSION

The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of these interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings suggest that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing efforts to provide high quality of care and life to the nation's 1.7 million nursing home residents.