Evidence-Based Practice Implementation: Dependent on Capacity and Capabilities

OBJECTIVE

This study was conducted to determine the benefits, facilitators, and barriers of implementing evidence-based practice (EBP) into organizational culture.

BACKGROUND

Implementing EBP leads to higher quality of patient outcome care, improved patient outcomes, and decreased healthcare costs. Nurse leader (NL) influence is essential for successful EBP implementation.

METHODS

Data were collected using a descriptive qualitative approach with focus group interviews using 2 open-ended questions. Participants included NL attendees at the 2022 Association of California Nurse Leaders Annual Program/Conference. Data were analyzed and themes were identified using Sandelowski's method.

RESULTS

Two overarching themes emerged: capacity (the amount something can produce) and capabilities (the power or ability to do something).

CONCLUSIONS

Healthcare organizations need to invest in building NLs' capacity to implement EBP and allocate resources to strengthen the organization's capabilities in supporting EBP.

Concurrent enrollment pathway: A model for ADN-BSN programs

INTRODUCTION

The purpose of this article is to share the collaborative planning and execution of these two public universities and one community college in developing an innovative program to increase BSN-prepared nurses. The aim of the collaboration is to offer a high quality, affordable, and time-saving pre-licensure, concurrent enrollment program (CEP) which allows community college ADN students direct access to BSN study, while maintaining excellent program outcomes, and increasing diverse baccalaureate-prepared nurses in practice.

METHODS

Key stakeholders in two public educational systems met to discuss the development of a regional collaboration between two state universities and one local community college. The group designed university-specific, concurrent curricular roadmaps for each university. Students admitted in ADN program chose if they want to attend a concurrent enrollment or a traditional plan of study.

RESULTS

In Fall 2019, the CEP program was launched admitting 40 ADN students concurrently enrolled in one university. Subsequently, another cohort started in Spring 2020 with 39 students dually enrolled at the other state university. All students in both cohorts resided in the region. Over 75 % of the total CEP enrollees came from diverse backgrounds, 49 % Hispanics, 16 %, Asians, and 8 % African Americans and 4 % native Hawaiians. Forty-four percent were first generation college students. The average age was 25 with a range of 21-39. Twenty percent of the students were male which is above the national average of 12 %. After four semesters, students completed their ADN degree, passed the licensure exam, and transitioned to earn their BSN degree in the university for another two semesters.

CONCLUSION

The literature reveals that BSN-prepared nurses contribute to safe patient care. The current number of cost-effective and accessible nursing programs are not sufficient to reach the IOM 80/20 goal, which contributes to the ongoing shortage of BSN-prepared nurses in the nation, including California. Creativity and open collaboration of nurse leaders, faculty, and staff across different levels of education was instrumental in the success of the students and the program.

Nursing's Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community

Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing's impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing's influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.

Long-Wave Infrared Imaging for Intraoperative Cancer Detection-What is the True Temperature of a Cancer?

BACKGROUND

During cancer operations, the cancer itself is often hard to delineate-buried beneath healthy tissue and lacking discernable differences from the surrounding healthy organ. Long-wave infrared, or thermal, imaging poses a unique solution to this problem, allowing for the real-time label-free visualization of temperature deviations within the depth of tissues. The current study evaluated this technology for intraoperative cancer detection.

METHODS

In this diagnostic study, patients with gastrointestinal, hepatobiliary, and renal cancers underwent long-wave infrared imaging of the malignancy during routine operations.

RESULTS

It was found that 74% were clearly identifiable as hypothermic anomalies. The average temperature difference was 2.4°C (range 0.7 to 5.0) relative to the surrounding tissue. Cancers as deep as 3.3 cm from the surgical surface were visualized. Yet, 79% of the images had clinically relevant false positive signals [median 3 per image (range 0 to 10)] establishing an accuracy of 47%. Analysis suggests that the degree of temperature difference was primarily determined by features within the cancer and not peritumoral changes in the surrounding tissue.

CONCLUSION

These findings provide important information on the unexpected hypothermal properties of intra-abdominal cancers, directions for future use of intraoperative long-wave infrared imaging, and new knowledge about the in vivo thermal energy expenditure of cancers and peritumoral tissue.

A Patient-Centric Tool to Facilitate Goal Attainment Scaling in Neurogenic Bladder and Bowel Dysfunction: Path to Individualization

OBJECTIVES

People with neurogenic bladder and/or bowel dysfunction experience diverse challenges that can be difficult to evaluate with standardized outcome measures. Goal attainment scaling (GAS) is an individualized, patient-centric outcome measure that enables patients/caregivers to identify and track their own treatment goals. Because creating goals de novo can be cumbersome, we aimed to develop a neurogenic bladder/bowel dysfunction goal menu to facilitate goal attainment scaling uptake and use.

METHODS

We conducted a workshop with 6 expert clinicians to develop an initial menu. Individual interviews with 12 people living with neurogenic bladder and/or bowel dysfunction and 2 clinician panels with 5 additional experts aided us in refining the menu. A thematic framework analysis identified emergent themes for analysis and reporting.

RESULTS

Interview participants were adults (median = 36 years, range 25-58), most with spinal cord injury (75%; 9/12). Of 24 goals identified initially, 2 (8%) were not endorsed and were removed, and 3 goals were added. Most participants listed "Impact on Life" goals (eg, Exercise, Emotional Well-Being) among their 5 most important goals (58%; 35/60). Three main themes emerged: challenges posed by incontinence, limitations on everyday life, and need for personalized care.

CONCLUSIONS

We developed a clinical outcome assessment tool following a multistep process of representative stakeholder engagement. This patient-centric tool consists of 25 goals specific to people living with neurogenic bladder and/or bowel dysfunction. Asking people what matters most to them can identify important constructs that clinicians might have overlooked.

Nursing workforce diversity: Promising educational practices

BACKGROUND

Nursing workforce diversity is a national priority for providing culturally competent care and contributing to improved health equity. While nurses from underrepresented populations are increasing in the nursing workforce, the distribution of nurses in the United States is still not representative of the population.

PURPOSE

The purpose of this paper is to describe the current state of workforce diversity in Western states and identify promising practices from programs located in Arizona, California, Colorado, and Oregon that are focused on improving nursing workforce diversity.

METHODS

Four innovative programs to address nursing workforce diversity are presented. Each project has unique situations and approaches to improving admission, retention, and graduation of students underrepresented in nursing. Similar approaches each project used include holistic admission review, academic and student support, financial support, and mentoring.

CONCLUSIONS

These projects contribute to knowledge development related to improving nursing workforce diversity for other colleges, universities, and states to consider. Improving nursing workforce diversity is a priority issue that could lead, through collective impact, to resolving health inequities nationally.

Active learning improves on-task behaviors in 4th grade children

While increased opportunities for physical activity (PA) are a critical, public health need for children, school-based interventions often place teachers in the position to choose between PA and time spent on academic lessons. Active learning is designed to overcome this by combining PA with academic material. Moreover, teachers are likely to be more responsive to change in academic-related outcomes than in PA. This study utilizes a large, cluster randomized control trial in which student attention, or time on task (TOT) and accelerometer-based PA is assessed in conjunction with active learning. Participants were 2716 children (46% male, 46% white) from 28 elementary schools in Central Texas that were assigned to either: 1) active learning (math n = 10; spelling n = 9); or 2) traditional, sedentary academic lessons (n = 9). PA was measured with accelerometers. TOT was measured through a momentary time sampling protocol. A series of three-level (student, classroom, school) regression models estimated the effect of the intervention. The intervention lead to significantly increased TOT. Moreover, the dose of PA (steps) during the intervention was positively associated with the increase in TOT. In contrast, a greater dose of PA was associated with reduced TOT for students in control schools. Race, gender, and SES did not moderate these effects. Planned PA - as a part of an active, academic lesson - positively impacted TOT. In contrast, a traditional, sedentary lesson was associated with lower TOT. This differential impact offers intriguing possibilities to better understand the relationship between PA and academic performance.

Factors associated with gerontological career choice: The role of curriculum type and students’ attitudes

Background and objective: Caring for a growing aging population presents a challenge in contemporary health care. This study aims to identify factors associated with nursing student’s career choice in older adult care and predictors of attitudes toward older adults. Such information is critical to inform effective gerontological nursing education.Methods: Undergraduate nursing students (N = 411) from three nursing schools in California participated in a cross-sectional, web-based survey.Results: In covariate-adjusted analyses, students who had prior experiences taking gerontology-related courses, working with older adults, living with older adults, being confident in providing older adults care, and having lower negative attitudes toward older adults were more likely to consider a future career in gerontological nursing. Students’ confidence in older adult care was negatively correlated with negative attitudes towards older adults.Conclusions: To increase students’ career choice in gerontology, nursing schools should provide more gerontology content in nursing curricula and explore avenues to increase student confidence in older adult care. 

Abstract NS9: ARN Professional Rehabilitation Nurse Competency Model: Application to Stroke Care

As the nursing profession continues to become more specialized, there have been more models developed to define specific practice areas. Rehabilitation nursing is practiced in diverse settings along the healthcare continuum with clients who have experienced a disability/chronic illness, such as stroke. No framework was noted in the literature that defined the necessary competencies of the rehabilitation nurse

Purpose: To develop a Competency Model for Professional Rehabilitation Nursing and its application to clinical practice.

Method: An Association of Rehabilitation Nurses’ (ARN) task force was convened, conducted a literature review and participated in “brainstorming” that yielded four domains of professional practice: nurse-led evidence-based interventions; promotion of health and successful living, leadership, and interprofessional practice; and essential role competencies. The competencies were further defined into three levels of proficiency: beginner, intermediate, and advanced (ARN, 2014).

Results: Model is a circle with professional rehabilitation nurse at the center surrounded by four domains and the role competencies, separated by broken lines illustrating the crossover of knowledge and skills represented in each domain. This practice Model can be used to inform stroke care in various settings across the healthcare continuum; and competencies such as facilitating safe and effective care transitions can be used in plan for the stroke survivor and caregiver. Facilitating the stroke survivor’s transition to the right level of care is an essential rehabilitation nurse competency and promotes better outcomes (Camicia et al., 2014). Using competencies, such as interventions based on best evidence, are essential in managing stroke sequela: neurogenic bladder, dysphagia, hemiplegia, etc. The Model can also be used to address the caregiver role and frame the assessment to determine education, community resource, and support needs.

Conclusion: ARN Rehabilitation Professional Nurse Competency Model reflects diversity of rehabilitation nursing in the current healthcare arena; and is an efficacious tool which can assist rehabilitation nurses at various levels to provide optimum stroke care and contribute to best practice.

The Competency Model for Professional Rehabilitation Nursing

BACKGROUND

Rehabilitation nursing is practiced in various settings along the healthcare continuum. No framework is noted in the literature that defines the necessary competencies of the rehabilitation nurse.

PURPOSE

To develop a Competency Model for Professional Rehabilitation Nursing and its application to clinical and educational practice.

METHOD/DESIGN

A seven-member Association of Rehabilitation Nurses (ARN) task force was convened; conducted a literature review, reviewed current and historical ARN documents, including the Strategic Plan, and developed a Competency Model for Professional Rehabilitation Nursing practice.

FINDINGS

The Competency Model for Professional Rehabilitation Nursing delineates four domains of rehabilitation nursing practice and essential role competencies.

CONCLUSION

The Competency Model for Professional Rehabilitation Nursing addresses this diverse specialty practice in the current healthcare arena. This framework can be used to guide nurses practicing at different levels of proficiency in various settings.

CLINICAL RELEVANCE

The Competency Model can be used as a structure for staff orientation, evaluation tools, clinical ladder components, role descriptions and rehabilitation nursing courses.

Abstract NS17: Caregiving Needs of Family Caregivers of Latino Stroke Survivors

Background/purpose: Latinos are at higher risk for stroke at a younger age due to multiple factors and stroke care is usually provided by family members in the home setting (familism). Caregiver information is procured in various ways; more often via “word of mouth” from family/friends versus healthcare providers. Culture, religion, and knowledge of stroke/resources or lack thereof, all impact the Latino caregiver. The purpose of this study was to examine perceived needs and resources of family caregivers of Latino stroke survivors.

Method: Ethnography was used to examine the perspectives/practices of Latino stroke caregivers. Participants were solicited from a Stroke Support Group in Southern CA. Data were collected via a focus group interview of six family caregivers in Spanish/English after informed consents were signed. Interview data/field notes were recorded. Thematic analysis of the interviews /notes was performed.

Results: The mean age of the caregivers was 35 years. The average number of daily care hours was reported as 10-12. All were new caregivers within the last 12 months. Three themes were revealed. The first theme was, “caring for family.” All caregivers received some information; however few sought outside resources related to language, finances, distrust of outside caregivers, or transportation. Caregivers served as “gatekeepers” regarding the stroke survivors’ health. Another theme was, “hope for survivor’s recovery.” Although some caregivers experienced fatigue and stress, they were optimistic for their loved one’s recovery. The third theme was, “what’s next?” Caregivers often did not know where to access resources beyond the MD office or clinic; expressed anxiety about outside services, and usually relied solely on family/friends for information and support.

Conclusions: Stroke family caregivers need providers to look “within culture “and be sensitive to the needs of the Latino family; provide caregiver classes in Spanish/English that highlight stroke/caregiver information, identify informal support, and seek affordable community options for services, such as stroke support groups in Latino communities; all of which can enhance the caregiver’s experience and promote positive stroke outcomes.

Stroke and heart disease prevention education via telenovela: a focus group's evaluation

PURPOSE

To evaluate a telenovela, "La Familia Nutritiva y Balanceada," for cultural context and its efficacy as an educational tool to promote positive health behaviors in Latino families.

METHOD

Ethnography was employed to interpret cultural health behaviors of 12 Latinas through a focus group after viewing the telenovela, a culturally accepted form of entertainment education.

RESULTS

Analysis of the transcribed interview revealed three recurrent themes: Not all fat is bad; add fruits and vegetables daily to diet; and children need to be involved. The group purported that the inclusion of children in the marketing and preparation of the food would translate into better food habits.

DISCUSSION

Participants demonstrated basic knowledge between food and health, and acknowledged that they gained an appreciation for good fat in the diet. The group related the telenovela would be a good tool for clinics, health fairs, and schools.

CONCLUSION

Latinos are at high risk for cardiovascular disease and stroke. Health education messages need to incorporate cultural norms into an intervention that supports a behavior change, such as improved nutrition. Studies support that Latinos connect to media, such as telenovela and interpersonal communication, which make these appropriate choices for health education tools.

Stroke and heart disease prevention education via telenovela: a focus group's evaluation

PURPOSE

To evaluate a telenovela, "La Familia Nutritiva y Balanceada," for cultural context and its efficacy as an educational tool to promote positive health behaviors in Latino families.

METHOD

Ethnography was employed to interpret cultural health behaviors of 12 Latinas through a focus group after viewing the telenovela, a culturally accepted form of entertainment education.

RESULTS

Analysis of the transcribed interview revealed three recurrent themes: Not all fat is bad; add fruits and vegetables daily to diet; and children need to be involved. The group purported that the inclusion of children in the marketing and preparation of the food would translate into better food habits.

DISCUSSION

Participants demonstrated basic knowledge between food and health, and acknowledged that they gained an appreciation for good fat in the diet. The group related the telenovela would be a good tool for clinics, health fairs, and schools.

CONCLUSION

Latinos are at high risk for cardiovascular disease and stroke. Health education messages need to incorporate cultural norms into an intervention that supports a behavior change, such as improved nutrition. Studies support that Latinos connect to media, such as telenovela and interpersonal communication, which make these appropriate choices for health education tools.

Factors influencing the participation of middle-aged and older Latin-American women in physical activity: a stroke-prevention behavior

Despite the known benefits of regular physical activity for preventing stroke and cardiovascular disease, middle-aged and older Latin-American women continue to be physically inactive and demonstrate a high incidence of obesity. Ethnographic methodology was used to explore factors that influenced this health behavior in 25 Latin-American women. Perceptions of health, the health activities in which they engaged, and the factors that influenced their participation in physical activity comprised the three categories of responses. Facilitators and barriers were identified as the two primary categories and were further sorted into intrinsic or extrinsic factors. Conclusions of this study were that these Latin American women, despite multiple role demands and other barriers, participated in some form of physical activity; however, culturally sensitive strategies are needed to promote sustained physical activity in this population.

Visual loss in children with neurofibromatosis type 1 and optic pathway gliomas: relation to tumor location by magnetic resonance imaging

PURPOSE

To examine the potential for visual acuity loss, and its relation to extent and location of optic pathway gliomas in a cohort of children with neurofibromatosis type 1 studied with magnetic resonance imaging.

METHODS

We reviewed the neuro-ophthalmologic records and brain/orbital magnetic resonance imaging scans for 43 consecutive pediatric patients with neurofibromatosis type 1 and optic pathway gliomas who were followed at the Children's Hospital of Philadelphia. The presence of visual loss, defined as abnormal visual acuity for age in one or both eyes, was determined. Optic pathway gliomas were classified by tumor extent and location according to involvement of the optic nerves, chiasm, and postchiasmal structures by magnetic resonance imaging.

RESULTS

Involvement of the optic tracts and other postchiasmal structures at tumor diagnosis was associated with a significantly higher probability of visual acuity loss (P =.048, chi-square test). Visual loss was noted in 20 of 43 patients (47%) at a median age of 4 years; however, three patients developed visual acuity loss for the first time during adolescence.

CONCLUSIONS

In pediatric patients with neurofibromatosis type 1 and optic pathway gliomas, the likelihood of visual loss is dependent on the extent and location of the tumor by magnetic resonance imaging and is particularly associated with involvement of postchiasmal structures. Furthermore, older age during childhood (adolescence) does not preclude the occurrence of visual loss. Close follow-up beyond the early childhood years, particularly for those with postchiasmal tumor, is recommended.

Grouping for reading instruction: does one size fit all?

Twenty-nine third-grade teachers and selected students from their classes participated. Study 1 used teacher interviews and classroom observations to examine teachers' perceptions and practices for grouping for reading instruction; Study 2 examined the impact of these grouping practices on the academic progress, social progress, and attitudes about reading of students representing a range of achievement levels, including students with learning disabilities. Results indicated that, overall, teachers used whole class instruction for reading and the same materials for all students, including students with learning disabilities. Students with learning disabilities made little academic progress and their attitudes about reading did not improve over time.

Adolescents with and without LD make the transition to middle school

The purpose of this 2-year study was to describe how Hispanic students with and without learning disabilities fared academically and socially during the transition from elementary school to middle school. Participants were 14 Hispanic students who were instructed in a sixth-grade consultation/collaboration, inclusive elementary classroom before making the transition to middle school. Examination of social, academic, and student perception data revealed that, on the whole, the students with learning disabilities and those without experienced the transition similarly and fared well during the elementary-to-middle-school transition.

Social outcomes for students with and without learning disabilities in inclusive classrooms

Social outcomes of students who participated in two different educational settings designed to provide special services for students with learning disabilities (LD) placed full-time within the general education classroom were examined. Participants were 185 third-through sixth-grade students: 59 students with LD, 72 low to average achieving, and 54 high achieving. There was an overall educational setting effect, with students on the consultation/collaborative teaching setting demonstrating more positive outcomes than students in the co-teaching setting on friendship quality and peer acceptance. Students with LD in the consultation/collaborative teaching setting also demonstrated moderate increases in the number of reciprocal friendships from fall to spring. Discussion addresses the positive social outcomes for students with LD and high-achieving students in the consultation/collaborative teaching setting, and the importance of monitoring student progress in all settings.

Inclusion or pull-out: which do students prefer?

The purpose of this study was to better understand students' perceptions of and preferences for inclusion or pull-out service delivery models. Thirty-two students with and without learning disabilities who had participated in both models during the past 2 or 3 years were interviewed individually. Key questions assessed their perceptions of which model was most conducive to academic learning and which was most likely to yield social benefits, and the reasons for their beliefs. Results indicated that students' views varied. Overall, more children identified pull-out as the model of choice, but many children were confident that inclusion was meeting their academic and social needs. We interpret the results of this study as providing support for maintaining a continuum of service delivery options and for considering the placement of each child individually, based on his or her unique needs.

What we know about using research findings: implications for improving special education practice

This article discusses the alternative roles and responsibilities that researchers might assume to bridge the gap between special education research and classroom practice. Literature is reviewed that addresses why some research-based practices fail, and the factors likely to lead to sustained use of research-based practices. The roles of researchers as collaborators, facilitators and coaches, interpreters of the culture and dynamics of the school, and critics are described in an attempt to promote researchers as leaders in efforts to improve practices in the field of special education.

The effects of inclusion on the social functioning of students with learning disabilities

The purpose of this study was to provide data on the social functioning (i.e., the degree of peer acceptance, self-concept, loneliness, and social alienation) of students in second, third, and fourth grade who participated in an inclusive classroom for an entire year. The social functioning of students identified as learning disabled (LD; n = 16), low achieving (LA; n = 27), and average/high achieving (AHA; n = 21) was assessed at the beginning and end of the school year. The students with LD were less well liked and more frequently rejected than AHA students. Although students' overall self-worth did not differ by achievement group, the students with LD demonstrated significantly lower academic self-concept scores. The students with LD did not differ on ratings of loneliness, and they demonstrated increases in the number of within-class reciprocal friendships from fall to spring. Discussion focuses on the effects of inclusion on the social functioning of students with LD.

Integration of pharmacology into a problem-based learning curriculum for medical students

The purpose of this study is threefold: (1) to describe a method of integration of pharmacology subject matter with other disciplines, in a problem-based learning (PBL) curriculum employed at the Northwest Center for Medical Education (NWCME), Indiana University School of Medicine; (2) to present various evaluation methods employed to assess students' learning of pharmacology knowledge; and (3) to compare the academic performance of students who underwent a traditional curriculum versus the PBL curriculum in terms of class evaluations and the standard national board medical licensure examinations. The PBL curriculum is designed for the first 2 years of medical education and consists of six sequential steps: steps 1 and 2 deal with biochemistry and anatomy respectively; steps 3, 4 and 5 deal with physiology, neuroscience and general pathology/microbiology respectively; and step 6 is a multidisciplinary step, which integrates basic science subjects with clinical medicine, emphasizing the mechanism of disease in an organ-system approach. In the PBL curriculum students start learning pharmacology within 6 months of admission. The content and process of pharmacology are spread across the first and in the second year. The pharmacology content is divided into three segments, each of which is integrated with other basic science subjects that have maximum mutual relevance. The three segments are as follows: the general and systemic pharmacology (50%) was included in step 3; the neuropharmacology and toxicology (35%) part was included in step 4; the third segment consisted of antimicrobial agents, anticancer and antiinflammatory agents (15%) and was included in step 5. The class evaluation of student performance in the PBL curriculum consisted of two elements, the content examinations and the process evaluations, which include the tutorial and the triple-jump evaluations of problem-solving skills. In order to assess the overall academic performance of the PBL curriculum and traditional curriculum groups, three classes of students who took the PBLC were compared with three classes of students who underwent a TC for performance in terms of class grades and scores of National Board examinations (NBMEI and/or USMLE I). The PBL curriculum students performed as well as or better than the TC students as measured by the NMBEI and/or USMLE I. The gain in pharmacology knowledge of PBL students is accompanied by the presence of a positive experience that learning pharmacology is enjoyable. Our experience suggests that the segmental integration approach of instruction coupled with a system of content (internal and external examinations) and process (tutorial and triple-jump) evaluations, as outlined in this paper is a contextualized learning method that offers an effective way of imparting pharmacology knowledge to medical students.

Responsible inclusion for students with learning disabilities

The purpose of this article is to contrast responsible with irresponsible inclusion practices for students with learning disabilities. Guidelines for responsible inclusion are that the student and family are considered first, teachers choose to participate in inclusion classrooms, adequate resources are provided for inclusion classrooms, models are developed and implemented at the school-based level, a continuum of services is maintained, the service delivery model is evaluated continuously, and ongoing professional development is provided.

Parent, teacher, peer, and self-reports of the social competence of students with learning disabilities

The social competence of students with learning disabilities (LD), low achievement (LA), and average to high achievement (AHA) was examined from the perspectives of parents, teachers, peers, and self, guided by a theoretical model of social competence (Vaughn & Hogan, 1990) that includes social skills, behavior problems, peer relations, and self-perceptions. Parent ratings of social skills did not differ significantly among achievement groups; however, for two factors of behavior problems (internalizing and hyperactivity), students with LD and LA were rated as having more problems than AHA students. Teachers perceived students with LD and LA as demonstrating poorer social skills and more behavior problems than AHA students. Peer ratings indicated that students with LD and LA were less likely by peers than were AHA students, yet only LA students received significantly higher peer rejection. Self-reports differentiated the groups on one factor: cooperation. Discussion focuses on the complexity of social competence as a construct, and explanations of the results are offered.

What do students with learning disabilities think when their general education teachers make adaptations?

The purpose of this study was to investigate the perceptions of mainstreamed students with learning disabilities (LD) regarding adaptations (e.g., altering tests, homework, assignments, instruction) made by general education teachers. Furthermore, their responses were compared with those of low achieving (LA) and average/high achieving (A/HA) classmates. One hundred seventy-nine students participated in this study: 60 mainstreamed students with LD, 59 low achieving students, and 60 average/high achieving students. Students were selected from 60 teachers' classrooms (20 elementary, 20 middle school, and 20 high school). Results from the elementary level indicate that students with LD differ from their LA and A/HA classmates in that the former indicate a stronger preference for opportunities to work in groups with different students, and prefer the teacher to make adaptations when they have difficulty learning. High school and middle school students from both the LA and A/HA groups, but not the LD group, preferred the teacher who made no adaptations in homework and textbooks. Discussion focuses on the role of students' perceptions in teacher decision making.

A four-year longitudinal investigation of the social skills and behavior problems of students with learning disabilities

This longitudinal, prospective study investigated the social skills and behavior problems of three groups of students (10 students per group) from kindergarten through third grade: learning disabilities (LD), low achievement (LA), and average/high achievement (A/HA). Social skills and behavior problem rating scales were completed by teachers on all students during kindergarten through third grade. Students in the LD and LA group exhibited significantly lower social skills and higher levels of behavior problems than their A/HA peers, but no significant differences for either measure were found between the LD and LA groups. Scores on the cooperating/responding factor of the social skills rating scale increased over time, but scores on the outgoing/initiating factor of the social skills rating scale did not change significantly over time. Discussion focused on the finding that students in the LD and LA groups did not differ significantly on social skills or behavior problems over time, though both groups demonstrated more behavior problems and lower social skills than the A/HA students.

Which motoric condition is most effective for teaching spelling to students with and without learning disabilities?

The purpose of this study was to determine the efficacy of three motoric conditions (writing, tracing, and computer keyboarding) on the spelling performance of 24 third- and fourth-grade students without learning disabilities (NLD) (15 males, 9 females) and 24 third- and fourth-grade students with learning disabilities (LD) (16 males, 8 females). This study applied empirically based procedures for teaching spelling, examined student performance over time, and incorporated student interviews concerning their preference for motoric condition. For number of words spelled and proportion of bi-grams (correct letter sequences) used correctly, significant differences were found between the LD and NLD groups, both at posttest and follow-up, with the NLD students learning to spell more words and apply more correct bi-grams than the students with LD. There was no significant effect for condition for either words spelled or bi-grams, indicating that students did not learn significantly more words in the writing, tracing, or computer condition. There was also a significant time effect indicating that the accuracy of both groups decreased over time from posttest to follow-up for both words and bi-grams. Interviews revealed that students in both groups preferred the computer condition; however, they believed that they learned best in the writing and tracing conditions.

Continuous monitoring of mixed venous oxygen saturation in patients with acute myocardial infarction

Continuous measurement of mixed venous oxygen saturation (SvO2) has been suggested as an adjunct in monitoring critically ill patients. We evaluated SvO2 monitoring in 24 patients suffering from complicated myocardial infarctions. Cardiac output and arterial lactate levels were measured when there were persistent 5 percent changes in SvO2, and otherwise, every 12 hours or as indicated clinically. Increases in SvO2 by 5 and 10 percent corresponded with an increase in cardiac index in 78.5 percent and 75 percent of measurements, respectively. Decreases in SvO2 by 5 and 10 percent corresponded with decreases in cardiac index in 45.5 percent and 61 percent of measurements. Twenty percent changes in cardiac index showed dissimilar directional changes with SvO2 in 62 percent of cases. Arterial blood lactate levels correlated poorly with SvO2. Survivors had significantly higher mean SvO2 and cardiac indices than nonsurvivors (p less than 0.01). The clinical management of patients with myocardial infarction may not be altered in view of the limitations of SvO2 in reflecting tissue hypoxia. We conclude that continuous monitoring of SvO2 may not be a sensitive measure of cardiac output after acute myocardial infarction.

Cardiac output changes and continuous mixed venous oxygen saturation measurement in the critically ill

For many years, the pulmonary artery catheter has been used to monitor cardiac filling pressures and to determine cardiac output in hemodynamically unstable patients. Recently, a new pulmonary artery catheter with fiberoptic capabilities, which provides continuous mixed venous O2 saturation (SvO2) measurements, has become available and has been found to be helpful in managing unstable patients. To determine the efficacy of this device in predicting early changes in cardiac output, we studied 46 patients catheterized with the opticath and 25 with the standard pulmonary artery catheter; we compared changes in the SvO2 with associated cardiac index changes. We found that small changes (5%) in SvO2 did not correlate well with changes in cardiac output, yet larger changes (10%) in SvO2 seemed to correlate better. More importantly, we found that only 50% of the SvO2 changes predicted anticipated changes in cardiac output. As can best be determined from the limitations of a nonrandomized study, the value of continuous SvO2 monitoring as an early predictor of cardiac output change remains questionable.

Chloroplast sulfhydryl groups and the light activation of fructose-1,6-bisphosphatase

Studies of isolated intact spinach (Spinacia oleracea L.) chloroplasts reveal that most of the available sulfhydryl groups are associated with stromal protein as opposed to a thylakoid membrane fraction under non-denaturing conditions. Increases in sulfhydryl content of approximately 50% occurred with illumination and could be correlated kinetically with a reductive activation of fructose-1,6-bisphosphatase during CO(2)-assimilation. Inhibition of linear electron flow with 3-(3,4-dichlorophenyl)-1,1-dimethylurea prevented light driven increases in both fructose-1,6-bisphosphatase activity and the relative sulfhydryl number. These results provide evidence for the operation of a reductive enzyme activating system in vivo.

Stress and smoking in hospital nurses

The smoking behavior of hospital nurses and the association between work-related stress and smoking were studied by means of a questionnaire mailed to the entire direct patient care nursing staff at the University of Michigan Hospital. Prevalence of smoking was considerably lower than in the US nurse population surveyed in 1975 and in the general female population of the same age range surveyed in 1978. Significantly higher scores were obtained for smokers than for non-smokers on scales concerning the physical and emotional stress of the job and the dissatisfaction with its rewards. The results supported more weakly the association of smoking with the perception of stress induced by role ambiguity, by nurse-doctor conflict, and by conflict between nurses. Some personal and situational variables were found to interact with perception of stress and smoking.