A qualitative study of advanced nurse practitioners’ use of physical assessment skills in the community: shifting skills across professional boundaries

Aim To explore multiple perspectives on the use of physical assessment skills by Advanced Nurse Practitioners in the UK Background Physical assessment skills practices are embedded in advanced nursing practice roles in the UK. There is little evidence on how these skills are used by Advanced Nurse Practitioners' on the community. Design Case study Methodology and methods. A qualitative interpretative single-embedded case study of 22 participants from South of England. A framework method analysed interview data collected by the researcher between March and August 2013. Participants included nurses, doctors, nurse educators and managers Findings Physical assessment skills education at Universities are part of a policy shift to develop a flexible workforce in the UK. Shared physical assessment practices are less to do with role substitution and more about preparing practitioners with skills that are fit for purpose. Competence capability and performance with physical assessment skills are an expectation of advanced nursing practice. Conclusions These skills are used successfully by community Advanced Nurse Practitioners to deliver a wide range of services in response to changing patient need. The introduction of physical assessment skills education to undergraduate professional preparation would create a firm foundation to develop these skills in post-graduate education. Relevance to clinical practice. • Physical assessment education prepares nurses with the clinical competencies to carry out healthcare reforms in the UK • Shared sets of clinical assessment competencies between disciplines have better outcomes for patients • Levels of assessment competence can depend on the professional attributes of individual practitioners • Unsupportive learning cultures can hinder professional development of advanced nursing practic

Selected Nick Adams Stories: Ernest Hemingway’s Sense of Place

This thesis examines how Ernest Hemingway’s use of natural imagery and physical elements in several of his semi-autobiographical Nick Adams stories offer insights into his character, especially Nick Adams. It analyzes Adams’s interactions with the physical world and compares these interactions with his interpersonal relationships and his own development. The short stories that this thesis examines include “Indian Camp,” “The Doctor and the Doctor’s Wife,” “Now I Lay Me,” “The End of Something,” “The Three Day Blow,” and “Big Two-Hearted River.” In these stories, Hemingway uses the natural world as a defense mechanism for Nick Adams, a character who turns to nature whenever he confronts problems or personal crises

Involvement of cytochromes P450 (CYP) and other haem associated enzymes in the bioreduction of AQ4N, an antitumour prodrug.

The anthraquinone di-N-oxide AQ4N is a prodrug designed to be excluded from cell nuclei until metabolised in hypoxic tumour regions to AQ4, a DNA binder and potent inhibitor of topoisomerase II. The antitumour effects of AQ4N in rodent neoplasms are well characterised but the identity of enzymes responsible for the metabolism are unknown. The aims of the present work were to identify Cytochrome P450 (CYP) enzymes responsible for AQ4N metabolism in rat and human tissue and to conduct a preliminary investigation into the in vivo metabolism of AQ4N in tumour bearing rodents. AQ4N was found to undergo a two electron reduction to the mono-Noxide AQM followed by a subsequent two electron reduction to cytotoxic AQ4. The process occurred in the microsomes of rat and human liver, was cofactor dependent and was inhibited by air. In rats, CYPs 2B and 2E were found to anaerobically metabolise both AQ4N and AQM. Kinetically, AQ4N metabolism conformed to a Michaelis-Menten model whereas the metabolism of AQM was better described by a sigmoidal relationship. In addition, both semi purified Cytochrome P450 reductase (CPR) and purified Nitric oxide synthase (NOS) were both able to anaerobically metabolise AQ4N. Both enzymes required NADPH and CPR mediated metabolism was dependent on the presence of exogenous haem. In humans, the anaerobic metabolism of both AQ4N and AQM correlated with CYP 3A activity and not with the activities of CYP 1 AI 2C and 2D. AQM metabolism correlated also with the activity of CYP 2A. The involvement of CYP 3A was confirmed by the use of CYP specific inhibitors and by the use of cDNA transfected cell microsomes. Human kidney and colonic tumours were found to anaerobically metabolise AQ4N and tumour metabolism was inhibited by the CYP inhibitor carbon monoxide (CO). Finally, the in vivo metabolism of AQ4N was studied in C3H tumour bearing mice. Metabolites of AQ4N were found in all tissues studied but the AQ4! AQ4N ratio was highest in the tumours. Collectively, these findings have identified the enzymes responsible for the metabolism of AQ4N and its mono-N-oxide. Differences exist between the CYP isoforms responsible for metabolism in rodents and in man, in humans, CYP 3A enzymes predominantly metabolise AQ4N and this subfamily of CYP are known to be well expressed in a broad spectrum of human cancers. With this in mind, AQ4N based therapy should be considered as a rational treatment regime for patients bearing solid tumour burdens

Undercutting the Biblical Inspiration and Authority Debate: The Hermeneutic of 2 Timothy 3:16-17 in Postmodernism against Black Liberation Theology

A resurgence of Black Liberation Theology has recently occurred in America, especially among proponents of Karl Barth and his contemporaries, James Cone, Robert McAfee Brown, and J. Deotis Roberts, to name a few. Black Liberation Theology and its concepts have been embraced in American culture via political, social, and economic media capable of bridging the divide between postmodernism and the church. Indeed, the avowal by certain prominent liberation theologians has been so widespread that their proposed theories have become synonymous with biblical truth among specific audiences. However, on the central issue of the denial of the authority and inspiration of Scripture, these liberation theologians’ interpretations have placed them in opposition to evangelicalism. Thus, Scripture is only “inspired” when God periodically speaks to individuals, whereas one must be suitable to Scripture— we are not masters of it but only objects of it. This inadequate belief devaluates the propositional revelatory essence of Scripture. Believing that another knowledge of God is possible, James Cone, whose Ph.D. dissertation was based on Barthian theology, proposed a “black theology,” a new concept that has taken flight as a global reconsideration of theological reflection that continues to this day. Using a thorough exegesis of 2 Timothy 3:16-17, this dissertation will argue that its components reinforce the doctrine of inspiration and authority of Scripture and undercut the hermeneutical perspective of postmodernism’s Black Liberation Theology. In addition, one will call on the Chicago Statement on Biblical Inerrancy to support this doctrinal position including diverse perspectives of inspiration from selected Scriptural and historical perspectives. The investigation will determine future dialog concerning various models that have shaped critical thinking over time