Producing Flexible Nurses: How Institutional Texts Organize Nurses’ Experiences of Learning to Work on Redesigned Nursing Teams (Préparer des infirmières polyvalentes : comment des documents officiels orientent les expériences d’apprentissage des infirmières en fonction du travail au sein d’équipes reconfigurées)

The purpose of this qualitative research was to utilize an Institutional Ethnographic (IE) lens to trace how various institutional (regulatory, educational, union, governmental, or health authority) texts and resources organize baccalaureate (RN) and diploma (vocational or practical) nurses’ experiences of learning to practice on acute care teams. Functional care models have been introduced in acute care, creating RN-LPN-health care aide (HCA) teams in conjunction with expanded practice scopes for LPNs. Questions arise as to how nurses (RNs and LPNs) learn to work together on these intra-professional teams. Beginning from the standpoint of front-line workers provides an entry-point into understanding how institutional priorities organize the everyday work of people. Ten RNs and ten LPNs were interviewed in two small community acute care hospitals on Vancouver Island. More specifically, in observations and interviews we looked for ways in which textually mediated work processes (such as regulatory, governmental, health authority, and educational documents) and other conceptual resources influenced nurses’ understandings of nursing education and professional practice. This analysis focused on how RNs and LPNs learn to work on re-designed nursing teams and traced the textually mediated discourses that are organizing this learning in the context of recent changes to LPN education and nursing teams. Our findings highlight unarticulated nursing knowledge/thinking, and the textual insertion of functional, skilled and flexible worker discourses, which organize to blur practice between RN and LPNs making them [potentially] interchangeable in complex acute care contexts. This study, situated as one analysis among a larger study, shows the invisibility of nursing disciplinary and professional goals and knowledge in nurses’ talk, as RNs and LPNs re-learn and sustain nursing practice in ways that fulfill other institutional and organizational goals. This re-alignment has significant implications for educators in nursing programs, who participate in teaching within educational silos. This research has shown that the absence of clarity in functional roles (perpetuating role confusion and ambiguity) is purposeful, with the goal of creating flexible workers. Résumé Cette étude qualitative selon une perspective d’ethnographie institutionnelle, visait à examiner comment divers documents institutionnels (réglementaires, académiques, syndicaux, gouvernementaux ou d’autorité régionale) orientent les expériences d’apprentissage des infirmières formées au baccalauréat (IB, en anglais RN) et des infirmières diplômées de formation professionnelle ou pratique (ID, en anglais LPN), en fonction de la pratique au sein d’équipes de soins aigus . L’intégration de modèles fonctionnels dans les soins aigus a entraîné la création d’équipes d’IBs-IDs- aides-soignantes et élargi la portée de la pratique des IDs. De cette situation surgissent des questions, à savoir comment les infirmières (IBs et IDs) apprennent à collaborer dans ces équipes intraprofessionnelles. Aborder la question du point de vue des travailleuses de première ligne offre une ouverture vers la compréhension de la manière dont les priorités institutionnelles organisent le travail quotidien de ces personnes. Nous nous sommes entretenues avec dix IB et dix ID de deux petits hôpitaux communautaires de soins aigus, sur l’île de Vancouver. Plus spécifiquement, à travers les observations et les entrevues, nous avons cherché les moyens par lesquels les processus de travail inscrits dans des textes institutionnels (documentation réglementaire, gouvernementale, d’autorité régionale et académique), ainsi que d’autres ressources conceptuelles, ont influencé la compréhension des infirmières quant à la formation et à la pratique professionnelle en sciences infirmières. Cette analyse était centrée sur la manière dont les IB et les ID apprennent à travailler au sein d’équipes infirmières reconfigurées et ciblait les énoncés de textes qui orientent cet apprentissage, dans le contexte des récents changements dans la formation des ID et au sein des équipes dont elles font partie. Nos résultats soulignent un savoir/ une pensée infirmière inexprimée et l’intégration textuelle d’un discours de travail fonctionnel, compétent et polyvalent qui contribuent à brouiller les pratiques entre les IB et les ID, les rendant [potentiellement] interchangeables en contexte de soins aigus complexes. Cette étude, qui ne représente qu’une analyse d’une étude plus large, démontre l’invisibilité de la discipline infirmière et des objectifs et savoirs professionnels dans le discours des infirmières, alors que les IB et les ID réapprennent et maintiennent une pratique infirmière qui répond à d’autres objectifs institutionnels et organisationnels. Cet ajustement a d’importantes répercussions pour les enseignantes des programmes de soins et sciences infirmières, qui évoluent de manière parallèle dans des établissements d’enseignement. Cette recherche démontre que l’absence de clarté dans les rôles fonctionnels (qui maintient la confusion de rôle et l’ambiguïté) est délibérée et vise à former des travailleuses polyvalentes

International genome-wide meta-analysis identifies new primary biliary cirrhosis risk loci and targetable pathogenic pathways.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Working to Full Scope: The Reorganization of Nursing Work in Two Canadian Community Hospitals

Work relationships between registered nurses (RNs) and practical nurses (LPNs) are changing as new models of nursing care delivery are introduced to create more flexibility for employers. In Canada, a team-based, hospital nursing care delivery model, known as Care Delivery Model Redesign (CDMR), redesigned a predominantly RN-based staffing model to a functional team consisting of fewer RNs and more LPNs. The scope of practice for LPNs was expanded, and unregulated health care assistants introduced. This study began from the standpoint of RNs and LPNs to understand their experiences working on redesigned teams by focusing on discourses activated in social settings. Guided by institutional ethnography, the conceptual and textual resources nurses are drawing on to understand these changing work relationships are explicated. We show how the institutional goals embedded in CDMR not only mediate how nurses work together, but how they subordinate holistic standards of nursing toward fragmented, task-oriented, divisions of care