Establishing a nurse practitioner collaborative: evolution, development, and outcomes

The first Australian palliative care nurse practitioner (NP) was endorsed in 2003. In 2009 the Victoria Department of Health funded the development of the Victorian Palliative Care Nurse Practitioner Collaborative (VPCNPC). Its aim was to promote the NP role, develop resources, and provide education and mentorship to NPs, nurse practitioner candidates (NPCs), and health service managers. Four key objectives were developed: identify the demographic profile of palliative care NPCs in Victoria; develop an education curriculum and practical resources to support the training and education of palliative care NPCs and NPs; provide mentorship to NPs, NPCs, and service managers; and ensure effective communication with all key stakeholders. An NPC survey was also conducted to explore NPC demographics, models of care, the hours of study required for the role, the mentoring process, and education needs. This paper reports on the establishment of the VPCNPC, the steps taken to achieve its objectives, and the results of the survey. The NP role in palliative care in Australia continues to evolve, and the VPCNPC provides a structure and resources to clearly articulate the benefits of the role to nursing and clinical services. The advanced clinical practice role of the nurse practitioner (NP) has been well established in North America for several decades and across a range of specialties (Ryan-Woolley et al, 2007; Poghosyan et al, 2012). The NP role in Australia and the UK is a relatively new initiative that commenced in the early 2000s (Gardner et al, 2009). There are over 1000 NPs across all states and territories of Australia, of whom approximately 130 work in the state of Victoria (Victorian Government Health Information, 2012). Australian NPs work across a range of specialties, including palliative, emergency, older person, renal, cardiac, respiratory, and mental health care. There has been increasing focus nationally and internationally on developing academic programmes specifically for nurses working toward NP status (Gardner et al, 2006). There has been less emphasis on identifying the comprehensive clinical support requirements for NPs and NP candidates (NPCs) to ensure they meet all registration requirements to achieve and/or maintain endorsement, or on articulating the ongoing requirements for NPs once endorsed. Historically in Australia there has been a lack of clarity and limited published evidence on the benefits of the NP role for patients, carers, and health services (Quaglietti et al, 2004; Gardner and Gardner, 2005; Bookbinder et al, 2011; Dyar et al, 2012). An NP is considered to be at the apex of clinical nursing practice. The NP role typically entails comprehensively assessing and managing patients, prescribing medicines, making direct referrals to other specialists and services, and ordering diagnostic investigations (Australian Nursing and Midwifery Council, 2009). All NPs in Australia are required to meet the following generic criteria: be a registered nurse, have completed a Nursing and Midwifery Board of Australia approved postgraduate university Master's (nurse practitioner) degree programme, and be able to demonstrate a minimum of 3 years' experience in an advanced practice role (Nursing and Midwifery Board of Australia, 2011). An NPC in Victoria is a registered nurse employed by a service or organisation to work toward meeting the academic and clinical requirements for national endorsement as an NP. During the period of candidacy, which is of variable duration, NPCs consolidate their competence to work at the advanced practice level of an NP. The candidacy period is a process of learning the new role while engaging with mentors (medical and nursing) and accessing other learning opportunities both within and outside one's organisation to meet the educational requirements. Integral to the NP role is the development of a model of care that is responsive to identified service delivery gaps that can be addressed by the skills, knowledge, and expertise of an NP. These are unique to each individual service. The practice of an Australian NP is guided by national standards (Nursing and Midwifery Board of Australia 2014). It is defined by four overarching standards: clinical, education, research, and leadership. Following the initial endorsement of four Victorian palliative care NPs in 2005, there was a lull in recruitment. The Victoria Department of Health (DH) recognised the potential benefits of NPs for health services, and in 2008 it provided funding for Victorian public health services to scope palliative care NP models of care that could enhance service delivery and patient outcomes. The scoping strategy was effective and led to the appointment of 16 palliative care nurses to NPC positions over the ensuing 3 years. The NPCs work across a broad range of care settings, including inpatient, community, and outpatient in metropolitan, regional, and rural areas of Victoria. At the same time, the DH also funded the Centre for Palliative Care to establish the Victorian Palliative Care Nurse Practitioner Collaborative (VPCNPC) to support the NPs and NPCs. The Centre is a state-wide service that is part of St Vincent's Hospital Melbourne and a collaborative Centre of the University of Melbourne. Its primary function is to provide training and conduct research in palliative care. The purpose of the VPCNPC was to provide support and mentorship and develop resources targeted at palliative care NPs, NPCs, and health service managers. Membership of the VPCNPC is open to all NPs, NPCs, health service managers, and nurses interested in the NP role. The aim of this paper is to describe the development of the VPCNPC, its actions, and the outcomes of these actions.

The emergence of bone technologies at the end of the pleistocene in Southeast Asia:Regional and evolutionary implications

For many decades Palaeolithic research viewed the development of early modern human behaviour as largely one of progress down a path towards the modernity of the present. The European Palaeolithic sequence the most extensively studied was for a long time the yard-stick against which records from other regions were judged. Recent work undertaken in Africa and increasingly Asia, however, now suggests that the European evidence may tell a story that is more parochial and less universal than previously thought. While tracking developments at the large scale (the grand narrative) remains important, there is growing appreciation that to achieve a comprehensive understanding of human behavioural evolution requires an archaeologically regional perspective to balance this. One of the apparent markers of human modernity that has been sought in the global Palaeolithic record, prompted by finds in the European sequence, is innovation in bonebased technologies. As one step in the process of re-evaluating and contextualizing such innovations, in this article we explore the role of prehistoric bone technologies within the Southeast Asian sequence, where they have at least comparable antiquity to Europe and other parts of Asia. We observe a shift in the technological usage of bone from a minor component to a medium of choice during the second half of the Last Termination and into the Holocene. We suggest that this is consistent with it becoming a focus of the kinds of inventive behaviour demanded of foraging communities as they adapted to the far-reaching environmental and demographic changes that were reshaping this region at that time. This record represents one small element of a much wider, much longerterm adaptive process, which we would argue is not confined to the earliest instances of a particular technology or behaviour, but which forms part of an on-going story of our behavioural evolution. © 2012 The McDonald Institute for Archaeological Research.

Use of eye care services among diabetic patients in urban and rural China.

OBJECTIVE: To assess the use of eye care and its predictors among diabetic patients in China. DESIGN: Cross-sectional, clinic-based study. PARTICIPANTS: Diabetic patients 18 years of age or older were recruited consecutively from an urban tertiary and community hospitals and from a rural clinic in Guangdong, China. METHODS: Information obtained by questionnaire and chart review included: demographic and socioeconomic status, knowledge about diabetic retinopathy (DR), and ocular and medical history. MAIN OUTCOME MEASURES: Self-reported or chart history of an eye examination ever or within the preceding 12 months. RESULTS: The participation rate among 889 eligible subjects was 92.7%. Among 824 participants (mean age, 62.6+/-12.9 years; 58.8% female), 550 (66.7%) had not been examined in the last year as recommended by the American Academy of Ophthalmology, and 356 (43.2%) had never been examined. For the rural hospital, these figures were 81.1% and 68.7%, respectively. In regression analyses, factors associated with having an eye examination in the last year were: attendance at urban hospitals (odds ratio [OR], 3.46 [P<0.001] and 1.76 [P = 0.021] for the tertiary and community hospitals, respectively, compared with the rural clinic), higher DR knowledge score (OR, 1.24; P = 0.001), greater concern about vision loss (OR, 1.22; P = 0.007), and recommendation of regular eye examinations by the provider (OR, 2.36; P = 0.011). Predictors of ever having an eye examination were similar. Monthly income and health insurance status were not predictive of being examined. CONCLUSIONS: These results suggest that the low proportion of diabetic receiving recommended annual eye examinations in China may be improved through patient and physician education. Copyright © 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Regional and urban air quality modelling under a climate change scenario

The better understanding of the interactions between climate change and air quality is an emerging priority for research and policy. Climate change will bring changes in the climate system, which will affect the concentration and dispersion of air pollutants. The main objective of the current study is to assess the impacts of climate change on air quality in 2050 over Portugal and Porto urban area. First, an evaluation and characterization of the air quality over mainland Portugal was performed for the period between 2002 and 2012. The results show that NO2, PM10 and O3 are the critical pollutants in Portugal. Also, the influence of meteorology on O3, NO2 and PM10 levels was investigate in the national main urban areas (Porto and Lisboa) and was verified that O3 has a statistically significant relationship with temperature in most of the components. The results also indicate that emission control strategies are primary regulators for NO2 and PM10 levels. After, understanding the national air quality problems and the influence that meteorology had in the historical air quality levels, the air quality modelling system WRF-CAMx was tested and the required inputs for the simulations were prepared to fulfil the main goal of this work. For the required air quality modelling inputs, an Emission Projections under RCP scenarios (EmiPro-RCP) model was developed to assist the estimation of future emission inventories for GHG and common air pollutants. Also, the current emissions were estimated for Portugal with a higher detailed disaggregation to improve the performance of the air quality simulations. The air quality modelling system WRF/CAMx was tested and evaluated over Portugal and Porto urban area and the results point out that is an adequate tool for the analysis of air quality under climate change. For this purpose, regional simulations of air quality during historical period and future (2045-2050) were conducted with CAMx version 6.0 to evaluate the impacts of simulated future climate and anthropogenic emission projections on air quality over the study area. The climate and the emission projections were produced under the RCP8.5 scenario. The results from the simulations point out, that if the anthropogenic emissions keep the same in 2050, the concentrations of NO2, PM10 and O3 will increase in Portugal. When, besides the climate change effects, is consider the projected anthropogenic emissions the annual mean concentrations of NO2 decrease significantly in Portugal and Porto urban area, and on the contrary the annual mean PM10 concentrations increases in Portugal and decrease in Porto urban area. The O3 results are mainly caused by the reduction of ozone precursors, getting the higher reductions in urban areas and increases in the surrounding areas. All the analysis performed for both simulations for Porto urban area support that, for PM10 and O3, there will be an increase in the occurrence of extreme values, surpassing the annual legislated parameters and having more daily exceedances. This study constitutes an innovative scientific tool to help in future air quality management in order to mitigate future climate change impacts on air quality.

Multi-agent simulation of continental, regional, and micro electricity markets

Renewable based power generation has significantly increased over the last years. However, this process has evolved separately from electricity markets, leading to an inadequacy of the present market models to cope with huge quantities of renewable energy resources, and to take full advantage of the presently existing and the increasing envisaged renewable based and distributed energy resources. This paper proposes the modelling of electricity markets at several levels (continental, regional and micro), taking into account the specific characteristics of the players and resources involved in each level and ensuring that the proposed models accommodate adequate business models able to support the contribution of all the resources in the system, from the largest to the smaller ones. The proposed market models are integrated in MASCEM (Multi- Agent Simulator of Competitive Electricity Markets), using the multi agent approach advantages for overcoming the current inadequacy and significant limitations of the presently existing electricity market simulators to deal with the complex electricity market models that must be adopted.

Prevalence of overweight and obesity in children from urban and rural Niagara

Purpose: The influence of environment in the development of overweight and obesity is an ongoing concern. This investigation examined the influence of urbanization on the rates of childhood overweight and obesity. Method: 2167 (1090M, 1077F) grade four children from 75 schools in Ontario's Niagara Region were sampled. A sophisticated algorithm overlaying electoral boundaries, population densities, and the knowledge of community members was used to classify schools into one of three location categories: urban {N= 1588), urban fringe {N= 379), and rural (A^= 234). Each subject was measured for: height, weight, and aerobic performance (Leger). Physical activity was evaluated with the self-report Participation Questionnaire (free-time and organized sport activities), and teacher's evaluations of student activity. Overweight (overweight and obesity combined) was measured both as a continuous (BMI) and categorical variable (BMI category), to evaluate the prevalence by location. A multivariate analysis was used to test for a suppression effect. Results: BMI and BMI category did not differ significantly by location or gender, and no evidence of a gender interaction existed. According to both a linear and logistic regression, physical activity or fitness levels did not suppress the influence of location on BMI and BMI category. Age, gender, free-time activity, organized sports, fitness level, and number of siblings, were all found to significantly influence overweight. Conclusions: It is plausible that the prevalence of overweight does not differ in urban and rural children from the Niagara Region. Further investigation is recommended, examining subjects by individual location of residence, in multiple regions throughout Ontario.

Ethnic conflicts and international politics : an analysis of the communal regional, and global dimensions of the Cyprus problem

The thesis assesses the impact of international factors on relations between Greek and Turkish Cypriots during and after the Cold War. Through an analysis of the Cyprus problem it explores both why external actors intervene in communal conflicts and how they influence relations between ethnic groups in plural societies. The analytical framework employed throughout the study draws on contributions of International Relations theorists and students of ethnic conflict. The thesis argues that, as in the global political system, relations between ethnic groups in unranked communal systems are anarchic; that is, actors within the system do not recognize a sovereign political authority. In bipolar communal systems dominated by two relatively equal groups, the struggle for security and power often leads to appeals for assistance from external actors. The framework notes that neighboring states and Great Powers may heed calls for assistance, or intervene without a prior request, if it is in their interest to do so. The convergence of regional and global interests in communal affairs exacerbates ethnic conflicts and precludes the development of effective political institutions. The impact of external intervention in ethnic conflicts has the potential to alter the basis of communal relations. The Cyprus problem is examined both during and after the Cold War in order to gauge how global and regional actors and the structure of their respective systems have affected relations between ethnic groups in Cyprus. The thesis argues that Cyprus's descent into civil war in 1963 was due in part to the entrenchment of external interests in the Republic's constitution. The study also notes that power politics involving the United States, Soviet Union, Greece and Turkey continued to affect the development of communal relations throughout the 1960s, 70s, and, 80s. External intervention culminated in July and August 1974, after a Greek sponsored coup was answered by Turkey's invasion and partition of Cyprus. The forced expulsion of Greek Cypriots from the island's northern territories led to the establishment of ethnically homogeneous zones, thus altering the context of communal relations dramatically. The study also examines the role of the United Nations in Cyprus, noting that its failure to settle the dispute was due in large part to a lack of cooperation from Turkey, and the United States' and Soviet Union's acceptance of the status quo following the 1974 invasion and partition of the island. The thesis argues that the deterioration of Greek-Turkish relations in the post-Cold War era has made a solution to the dispute unlikely for the time being. Barring any dramatic changes in relations between communal and regional antagonists, relations between Greek and Turkish Cypriots will continue to develop along the lines established in July/August 1974. The thesis concludes by affirming the validity of its core hypotheses through a brief survey of recent works touching on international politics and ethnic conflict. Questions requiring further research are noted as are elements of the study that require further refinement.