Acute care nurses' perceptions of barriers to using research information in clinical decision-making

Aim. To examine the barriers that nurses feel prevent them from using research in the decisions they make. Background. A sizeable research literature focusing on research utilization in nursing has developed over the past 20 years. However, this literature is characterized by a number of weaknesses: self-reported utilization behaviour; poor response rates and small, nonrandom sampling strategies. Design. Cross-case analysis involving anonymised qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 h, and 122 nurses were involved in the Q modelling exercise (response rate of 64%). Results. Four perspectives were isolated that encompassed the characteristics associated with barriers to research use. These related to the individual, organization, nature of research information itself and environment. Nurses clustered around four main perspectives on the barriers to research use: (1) Problems in interpreting and using research products, which were seen as too complex, 'academic' and overly statistical; (2) Nurses who felt confident with research-based information perceived a lack of organizational support as a significant block; (3) Many nurses felt that researchers and research products lack clinical credibility and that they fail to offer the desired level of clinical direction; (4) Some nurses lacked the skills and, to a lesser degree, the motivation to use research themselves. These individuals liked research messages passed on to them by a third party and sought to foster others' involvement in research-based practice, rather than becoming directly involved themselves. Conclusions. Rejection of research knowledge is not a barrier to its application. Rather, the presentation and management of research knowledge in the workplace represent significant challenges for clinicians, policy-makers and the research community

The accessibility of research-based knowledge for nurses in United Kingdom acute care settings

Background. The successful dissemination of the results of the National Health Service (NHS) research and development strategy and the development of evidence based approaches to health care rely on clinicians having access to the best available evidence; evidence fit for the purpose of reducing the uncertainties associated with clinical decisions. Aim. To reveal the accessibility of those sources of information actually used by nurses, as well as those which they say they use. Design. Mixed method case site, using interview, observational, Q sort and documentary audit data in medical, surgical and coronary care units (CCUs) in three acute hospitals. Results. Three perspectives on accessibility were identified: (a) the humanist-in which human sources of information were the most accessible; (b) local information for local needs-in which locally produced resources were seen as the most accessible and (c) moving towards technology-in which information technology begins to be seen as accessible. Nurses' experience in a clinical specialty is positively associated with a perception that human sources such clinical nurse specialists, link nurses, doctors and experienced clinical colleagues are more accessible than text based sources. Clinical specialization is associated with different approaches to accessing research knowledge. Coronary care unit nurses were more likely perceive local guidelines, protocols and on-line databases as more accessible than their counterparts in general medical and surgical wards. Only a third of text-based resources available to nurses oil the wards had any explicit research base. These, and the remainder were Out of date (mean age of textbooks 11 years), and authorship hard to ascertain. Conclusion. A strategy to increase the use of research evidence by nurses should harness the influence of clinical nurse specialists, link nurses and those engaged in practice development. These roles Could act as 'conduits' through which research-based messages for practice, and information for clinical decision making, could flow. This role should be explored and enhanced

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P <0.002) and orlistat for obesity (P <0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer’s disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context

Recurrent geomagnetic storms and relativistic electron enhancements in the outer magnetosphere: ISTP coordinated measurements

New, coordinated measurements from the International Solar-Terrestrial Physics (ISTP) constellation of spacecraft are presented to show the causes and effects of recurrent geomagnetic activity during recent solar minimum conditions. It is found using WIND and POLAR data that even for modest geomagnetic storms, relativistic electron fluxes are strongly and rapidly enhanced within the outer radiation zone of the Earth\u27s magnetosphere. Solar wind data are utilized to identify the drivers of magnetospheric acceleration processes. Yohkoh solar soft X-ray data are also used to identify the solar coronal holes that produce the high-speed solar wind streams which, in turn, cause the recurrent geomagnetic activity. It is concluded that even during extremely quiet solar conditions (sunspot minimum) there are discernible coronal holes and resultant solar wind streams which can produce intense magnetospheric particle acceleration. As a practical consequence of this Sun-Earth connection, it is noted that a long-lasting E\u3e1MeV electron event in late March 1996 appears to have contributed significantly to a major spacecraft (Anik E1) operational failure

Redox Chemistry and Molybdenum Burial in a Mesoproterozoic Lake

While marine sediments have been used to constrain a history of redox chemistry throughout the Precambrian, far fewer data have been generated from lakes. With major biological innovations thought to have occurred in Proterozoic lakes, understanding their chemistry is critical for understanding the evolution of eukaryotic life. We use sediment geochemistry to characterize the redox conditions of the Nonesuch Formation (~1.1 Ga) and a modern analogue for the Proterozoic: the Middle Island Sinkhole in Lake Huron (USA). Iron speciation, Mo contents, and Mo‐U covariation demonstrate oxic and anoxic—not euxinic—environments, with no clear indicators of enhanced biological productivity in the Nonesuch Formation. Moderate Mo enrichments observed in the Nonesuch Formation are not attributed to euxinia, but instead to an authigenic particulate shuttle. We suggest that the Fe and Mo sediment geochemistry of these lacustrine systems reflect only local water column and sediment burial conditions and not atmospheric oxygenation.Plain Language SummaryLakes are proposed to have been critical environments for the evolution of life during the Proterozoic (~2.5 to 0.5 billion years ago). However, relatively little is known about the chemistry of ancient lakes, including the availability of oxygen for biological productivity, and how local oxygen availability can be extrapolated to understand global oxygen availability. In addition, with no lakes remaining from the Proterozoic, the only way to study ancient lakes is to use the chemistry of the sediments left behind. This study uses the sediment chemistry of elements that are sensitive to oxygen to understand oxygen availability in a Proterozoic lake environment. These data were then compared to modern lake environments with known chemistry and oxygen levels in order to interpret the results better. We found that oxygen availability in the Proterozoic lake was variable, with no clear indicators of abundant biological productivity. We conclude that ancient lake sediments only constrain the chemistry of the local environment, with no major implications for global or even regional atmospheric oxygenation.Key PointsFe, Mo, and U sediment geochemistry of the Nonesuch Formation (~1.1 Ga; USA) indicate fluctuating oxic and anoxic redox chemistryMo and U covariation in the Nonesuch Formation and modern analogue sediments confirm euxinia is not necessary for moderate Mo burialComparison of Nonesuch Formation and modern analogue indicates that Proterozoic lakes are unlikely to constrain atmospheric oxygenPeer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150528/1/grl59087_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150528/2/grl59087.pd

Independent Assessment of the 2018–19 fish deaths in the lower Darling

Three significant fish death events occurred in the Darling River near Menindee between December 2018 and January 2019. The three events took place within two adjacent weir pools in a 30 km reach of river between Texas Downs Station and Weir 32 (DPI NSW Fisheries, 2019). The main native fish species involved included Murray Cod, Silver Perch, Golden Perch, Bony Herring, with mortality estimates in the range of hundreds of thousands to over a million fish. Though post-event fish population sampling is yet to be conducted, we expect that these mortalities will impact populations in the lower Darling River, and perhaps beyond, for many years. These events constitute a serious ecological shock to the lower Darling and reverse positive ecological outcomes that had accrued from environmental watering programs. We have determined that fish deaths events were primarily caused by local hydrological and climatic conditions (Figure 1-1). The extreme hot and dry climate during 2018, extending into 2019, shaped the conditions that saw a large fish biomass, which had flourished since favourable spawning conditions in 2016, isolated in the weir pools around Menindee, with no means of escaping upstream or downstream. Those adverse climate conditions also shaped the subsequent algal bloom development and the strong and persistent thermal stratification of the weir pools, which created hypoxic conditions in the bottom waters of the pools. All that was needed for this to have a fatal impact on the fish was a trigger for the weir pool waters to become destratified and deprive the fish of oxygen. That trigger duly arrived with a series of sudden cool changes in the weather, with temperature drops and wind action initiating the turnover of the weir pool waters. This sudden depletion of oxygen, combined with the already high water and air temperatures, would have offered the large biomass of stressed fish no means of escape. For each fish death event, the weir pool in which the fish were trapped was bordered downstream by an impenetrable barrier (a weir) and upstream by a dry channel. Ultimately, it was the rapid transition from very favourable conditions to very adverse ones that resulted in such high numbers of fish deaths. We have also determined that the fish death events were shaped by a broader climatic, hydrologic and basin management context that placed the lower Darling River at risk of such fish deaths. The preceding six years (since 2012) had seen two high flow events that had delivered water into Menindee Lakes (2012 and 2016) and offered opportunities for substantial fish breeding and recruitment. Fish populations were further enhanced by the judicious use of environmental water. The end result was a considerable biomass of fish within the Menindee Lakes, post 2016. Outside of these high flow events there were minimal flows in the Darling River below Bourke. This period was preceded by the Millennium drought (2000-2010), during which time flows across the entire northern Murray– Darling Basin were reduced. All of the hydroclimatic evidence available indicates that the years since 2000 have been some of the driest on record, in terms of inflows into major upstream storages, combined with an increased number of extreme heat days, which would have had a major impact on water quality in remnant pools. Soon after the events, Basin government officials met and developed an action plan to respond to the crisis. Immediate actions underway include additional water quality monitoring in the lower Darling, the use of aerators and targeted fish relocations. These immediate actions are welcomed, however, the current situation remains critical – without significant inflows, further deaths of surviving fish may be expected. We consider that priorities and actions in the short-term should focus on anticipating a repeat of ‘worst-case scenario’ outcomes with responses focussed at the site scale. In addition, the Minister for Agriculture and Water Resources announced a Native Fish Management and Recovery Strategy to help manage and recover fish populations across the Basin. We consider that this provides a good opportunity to enhance native fish management and support native fish population recovery and should be developed and implemented through a genuine collaboration between governments, communities, and Traditional Owners. The strategy needs to build on existing and lapsed native fish programs across the Basin. Through our investigations, it became evident to us that, over the long-term, the extant water access arrangements in the northern Basin, as well as limitations in the river models used to plan water sharing, place the lower Darling River at a higher risk of conditions that can lead to fish deaths during droughts than has previously been anticipated. Given that we are witnessing an increasing frequency of low inflow sequences in the northern Basin, this presents a serious problem for safeguarding fish populations, and populations of other resident biota, during drought in the lower Darling. We have identified that changes to Barwon–Darling water access arrangements made by NSW just prior to the commencement of the Basin Plan in 2012 have enhanced the ability of irrigators to access water during low flow periods and during the first flow event immediately after a cease-to-flow period. Further, it appears that the river models used to develop water sharing arrangements have a tendency to overestimate streamflows during dry sequences, and hence underestimate the impacts of extractions during dry times

Locality and Causality in Hidden Variables Models of Quantum Theory

Motivated by Popescu's example of hidden nonlocality, we elaborate on the conjecture that quantum states that are intuitively nonlocal, i.e., entangled, do not admit a local causal hidden variables model. We exhibit quantum states which either (i) are nontrivial counterexamples to this conjecture or (ii) possess a new kind of more deeply hidden irreducible nonlocality. Moreover, we propose a nonlocality complexity classification scheme suggested by the latter possibility. Furthermore, we show that Werner's (and similar) hidden variables models can be extended to an important class of generalized observables. Finally a result of Fine on the equivalence of stochastic and deterministic hidden variables is generalized to causal models.Comment: revised version, 21 pages, submitted to Physical Review

Cyanobacterial life at low O 2 : community genomics and function reveal metabolic versatility and extremely low diversity in a Great Lakes sinkhole mat

Cyanobacteria are renowned as the mediators of Earth’s oxygenation. However, little is known about the cyanobacterial communities that flourished under the low‐O 2 conditions that characterized most of their evolutionary history. Microbial mats in the submerged Middle Island Sinkhole of Lake Huron provide opportunities to investigate cyanobacteria under such persistent low‐O 2 conditions. Here, venting groundwater rich in sulfate and low in O 2 supports a unique benthic ecosystem of purple‐colored cyanobacterial mats. Beneath the mat is a layer of carbonate that is enriched in calcite and to a lesser extent dolomite. In situ benthic metabolism chambers revealed that the mats are net sinks for O 2 , suggesting primary production mechanisms other than oxygenic photosynthesis. Indeed, 14 C‐bicarbonate uptake studies of autotrophic production show variable contributions from oxygenic and anoxygenic photosynthesis and chemosynthesis, presumably because of supply of sulfide. These results suggest the presence of either facultatively anoxygenic cyanobacteria or a mix of oxygenic/anoxygenic types of cyanobacteria. Shotgun metagenomic sequencing revealed a remarkably low‐diversity mat community dominated by just one genotype most closely related to the cyanobacterium Phormidium autumnale , for which an essentially complete genome was reconstructed. Also recovered were partial genomes from a second genotype of Phormidium and several Oscillatoria . Despite the taxonomic simplicity, diverse cyanobacterial genes putatively involved in sulfur oxidation were identified, suggesting a diversity of sulfide physiologies. The dominant Phormidium genome reflects versatile metabolism and physiology that is specialized for a communal lifestyle under fluctuating redox conditions and light availability. Overall, this study provides genomic and physiologic insights into low‐O 2 cyanobacterial mat ecosystems that played crucial geobiological roles over long stretches of Earth history.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90535/1/j.1472-4669.2012.00322.x.pd

The organisational and human resource challenges facing primary care trusts : protocol of a multiple case study

BACKGROUND: The study is designed to assess the organisational and human resource challenges faced by Primary Care Trusts (PCTs). Its objectives are to: specify the organisational and human resources challenges faced by PCTs in fulfilling the roles envisaged in government and local policy; examine how PCTs are addressing these challenges, in particular, to describe the organisational forms they have adopted, and the OD/HR strategies and initiatives they have planned or in place; assess how effective these structures, strategies and initiatives have been in enabling the PCTs to meet the organisational and human resources challenges they face; identify the factors, both internal to the PCT and in the wider health community, which have contributed to the success or failure of different structures, strategies and initiatives. METHODS: The study will be undertaken in three stages. In Stage 1 the key literature on public sector and NHS organisational development and human resources management will be reviewed, and discussions will be held with key researchers and policy makers working in this area. Stage 2 will focus on detailed case studies in six PCTs designed to examine the organisational and human resources challenges they face. Data will be collected using semi-structured interviews, group discussion, site visits, observation of key meetings and examination of local documentation. The findings from the case study PCTs will be cross checked with a Reference Group of up to 20 other PCG/Ts, and key officers working in organisational development or primary care at local, regional and national level. In Stage 3 analysis of findings from the preparatory work, the case studies and the feedback from the Reference Group will be used to identify practical lessons for PCTs, key messages for policy makers, and contributions to further theoretical development