Development and Implementation of the Use of Optically Stimulated Luminescent Detectors in the Radiological Physics Center Anthropomorphic Quality Assurance Phantoms

The Radiological Physics Center (RPC) uses both on-site and remote reviews to credential institutions for participation in clinical trials. Anthropomorphic quality assurance (QA) phantoms are one tool the RPC uses to remotely audit institutions, which include thermoluminescent dosimeters (TLDs) and radiochromic film. The RPC desires to switch from TLD as the absolute dosimeter in the phantoms, to optically stimulated luminescent dosimeters (OSLDs), but a problem lies in the angular dependence exhibited by the OSLD. The purpose of this study was to characterize the angular dependence of OSLD and establish a correction factor if necessary, to provide accurate dosimetric measurements as a replacement for TLD in the QA phantoms. A 10 cm diameter high-impact polystyrene spherical phantom was designed and constructed to hold an OSLD to study the angular response of the dosimeter under the simplest of circumstances for both coplanar and non-coplanar treatment deliveries. OSLD were irradiated in the spherical phantom, and the responses of the dosimeter from edge-on angles were normalized to the response when irradiated with the beam incident normally on the surface of the dosimeter. The average normalized response was used to establish an angular correction factor for 6 MV and 18 coplanar treatments, and for 6 MV non-coplanar treatments specific to CyberKnife. The RPC pelvic phantom dosimetry insert was modified to hold OSLD, in addition to the TLD, adjacent to the planes of film. Treatment plans of increasing angular beam delivery were developed, three in Pinnacle v9.0 (4-field box, IMRT, and VMAT) and one in Accuray’s MultiPlan v3.5.3 (CyberKnife). The plans were delivered to the pelvic phantom containing both TLD and OSLD in the target volume. The pelvic phantom was also sent to two institutions to be irradiated as trials, one delivering IMRT, and the other a CyberKnife treatment. For the IMRT deliveries and the two institution trials, the phantom also included film in the sagittal and coronal planes. The doses measured from the TLD and OSLD were calculated for each irradiation, and the angular correction factors established from the spherical phantom irradiations were applied to the OSLD dose. The ratio of the TLD dose to the angular corrected OSLD dose was calculated for each irradiation. The corrected OSLD dose was found to be within 1% of the TLD measured dose for all irradiations, with the exception of the in-house CyberKnife deliveries. The films were normalized to both TLD measured dose and the corrected OSLD dose. Dose profiles were obtained and gamma analysis was performed using a 7%/4 mm criteria, to compare the ability of the OSLD, when corrected for the angular dependence, to provide equivalent results to TLD. The results of this study indicate that the OSLD can effectively be used as a replacement for TLD in the RPC’s anthropomorphic QA phantoms for coplanar treatment deliveries when a correction is applied for the dosimeter’s angular dependence.

Exploring a model of skillful engagement in nursing practice

Prominent challenges facing nurse leaders are the growing shortage of nurses and the increasingly complex care required by acutely ill patients. In organizations that shortage is exacerbated by turnover and intent to leave. Unsatisfactory working conditions are cited by nurses when they leave their current jobs. Disengagement from the job leads to plateaued performance, decreased organizational commitment, and increased turnover. Solutions to these challenges include methods both to retain and to increase the effectiveness of each nurse. ^ The specific aim of this study was to examine the relationships among organizational structures thought to foster the clinical development of the nurse, with indicators of the development of clinical expertise, resulting in outcomes of positive job attitudes and effectiveness. Causal loop modeling is incorporated as a systems tool to examine developmental cycles both for an organization and for an individual nurse to look beyond singular events and investigate deeper patterns that emerge over time. ^ The setting is an academic specialty-care institution, and the sample in this cross-sectional study consists of paired data from 225 RNs and their nurse managers. Two panels of survey instruments were created based on the model's theoretical variables, one completed by RNs and the other by their Nurse Managers. The RN survey panel examined the variables of structural empowerment, magnet essentials, knowledge as identified by the Benner developmental stage, psychological empowerment, job stage, engagement, intent to leave, job satisfaction and the early recognition of patient complications. The nurse manager survey panel examined the Benner developmental stage, job stage, and overall level of nursing performance. ^ Four regression models were created based on the outcome variables. Each model identified significant organizational and individual characteristics that predicted higher job satisfaction, decreased intent to leave, more effectiveness as measured by early recognition and acting upon subtle patient complications, and better job performance. ^ Implications for improving job attitudes and effectiveness focus on ways that nursing leaders can foster a more empowering and healthy work environment. ^

Planning, implementation, and evaluation of an HIV -screening program for pregnant women

The purpose of this study was to evaluate the effectiveness of an HIV-screening program at a private health-care institution where the providers were trained to counsel pregnant women about the HIV-antibody test according to the latest recommendations made by the U.S. Public Health Service (PHS) and the Texas legislature. A before-and-after study design was selected for the study. The participants were OB/GYN nurses who attended an educational program and the patients they counseled about the HIV test. Training improved the nurses' overall knowledge about the content of the program and nurses were more likely to offer the HIV test to all pregnant women regardless of their risk of infection. Still, contrary to what was predicted, the nurses did not give more information to increase the knowledge pregnant women had about HIV infection, transmission, and available treatments. Consequently, many women were not given the chance to correctly assess their risk during the counseling session and there was no evidence that knowledge would reduce the propensity of many women to deny being at risk for HIV. On the other hand, pregnant women who received prenatal care after the implementation of the HIV-screening program were more likely to be tested than women who received prenatal care before its implementation (96% vs. 48%); in turn, the likelihood that more high-risk women would be tested for HIV also increased (94% vs. 60%). There was no evidence that mandatory testing with right of refusal would deter women from being tested for HIV. When the moment comes for a woman to make her decision, other concerns are more important to her than whether the option to be tested is mandatory or not. The majority of pregnant women indicated that their main reasons for being tested were: (a) the recommendation of their health-care provider; and (b) concern about the risks to their babies. Recommending that all pregnant women be tested regardless of their risk of infection, together with making the HIV test readily available to all women, are probably the two best ways of increasing the patients' participation in an HIV-screening program for pregnant women. ^